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Based on observation and interviews with the maintenance director, the facility failed to maintain fire protection and occupant safety features necessary to minimize the spread of fire and the products of combustion areas of the building occupied by patients, staff and the public. The facility did not maintain the firestopping required for penetrations in rated assemblies. Per NFPA 101 Ch. 8.3.5.1, "Penetrations for cables, cable trays, conduits, pipes, tubes combustion vents . . . .and similar items. . . .that pass through a wall, floor, ceiling or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. . . ."
Findings are:
During the Life Safety Survey on November 8 and 9th, 2011 with the maintenance director we gained access to the CPCU communications closet and observed the following condition that would allow smoke and fire to enter the occupied space above.
At 1:55 p.m., November 9th, the floor/ceiling assembly was inspected and it was discovered that holes were drilled through the floor/ceiling to install electrical conduit from the equipment located in the room. The penetrations became un-sealed by an approved firestopping device or method when the fire caulk fell out of the metal sleeve installed for passing wires through the openings. Additionally, the annular spaces around the metal sleeves were unsealed. This condition creates vertical openings in the rated assembly and will allow fire and heated gases to enter the occupied space above.
Note: It is recommended that all vertical penetrations be inspected by maintenance personnel throughout the facility and sealed with an approved firestopping method.
These findings were re-confirmed during the exit conference with the Administrator at 4:30 p.m. on November 9th, 2011.

Based on an observation and interviews, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke and fire barriers per NFPA 101-2006 , 4.6.12.1-.4, "Features required by the Code...shall be thereafter permanently maintained." Three (3) out of 10 sampled smoke/fire barrier walls had unsealed penetrations.
This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants. Unsealed penetrations in rated walls did not demonstrate compliance with the code standard. It is required that breaches and penetrations of all fire/smoke barriers be appropriately repaired and the walls / ceilings brought back to their original fire rated integrity. This would then restrict the movement of fire and smoke and help to ensure the safety of occupants within the facility in a fire emergency. These penetrations must be resealed with an approved firestopping method on both sides of each penetration.

Findings are:

During the life safety tour and observations with the facilities supervisor on November 8th and 9th, 2011, the following walls were not maintained to limit the transfer of smoke/heated gases should a fire occur.
At 9:45 a.m. on November 8th, observed that the rated wall in the south corridor in the wound care area of the building had an unsealed penetration. Ceiling tiles were displaced to allow visualization of the smoke/fire barrier and an unsealed penetration was discovered.
At 11:15 a.m. on November 9th, 2011 the ceiling tiles were displaced near patient room #401 in order to observe the smoke/fire barrier wall. It was determined that a penetration through the wall was unsealed in a sleeve provided for electrical wiring.
At 11.30 a.m. on November 9th, 2011 the ceiling above the cross corridor fire doors was displaced to observe the smoke wall. It was discovered to have unsealed penetrations in the rated assembly.
These findings were re-confirmed with the facilities director during the closing conference at 4:30 p.m. on November 9th, 2011.
NOTE: These examples are not to be considered as the only penetrations of the building's fire/smoke barrier walls. A thorough inspection of each fire/smoke barrier must be made along the full length and height of each wall to ensure that all penetrations are found and properly sealed.

Based on observation, testing and interviews with the facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to patients, staff and the public from fire, smoke and panic should a fire occur. The facility did not maintain doors sampled during the survey that are designed to separate hazardous areas. Testing revealed doors that would not close completely and latch or that lacked the required self-closing devices in several locations in the facility. NFPA 101-2006, 4.6.12.1 requires that features "shall be continuously maintained in in proper operating condition. . . ." Also per NFPA 101 2006, 19.3.2.1, "the area shall be separated from the other spaces by smoke-resistant partitions and doors. . . ." Lack of separation due to required door features could allow smoke and fire gasses to quickly spread in the event of a fire. Additionally, per Chapter 39.3.2.2, "Hazardous areas including, but not limited to, areas used for general storage. . . .shall be protected in accordance with Section 8.7." Per Section 8.7.1.1, "Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building. . . .shall be provided. . . ." by (1) "Enclosing the area with a fire barrier. . . .in accordance with Section 8.3."

Findings are:

During the life safety tour of the facility on November 8, 2011 with the director of maintenance, observed that the following doors would not function to limit the transfer of smoke and the products of combustion should a fire occur.

Observation and testing of the door to the storage/mechanical room near the pool in the 611 building, (physical therapy) at 9:45 a.m. revealed that the door lacked the required door closer. Interview with the maintenance director evidenced that the room has been used for storage for several months. Since the room is used for storage and is larger than 50 square feet in area, a closing mechanism is required by the code. Storage also included several containers of flammable liquids and pool chemicals. Flammable liquids are required to be contained by an approved type storage locker per NFPA 30.
At 10:30 a.m., in the wound care area of the building, the door to the soiled utility room did not feature the required self-closing mechanism.
At 1:50 pm testing revealed that the self-closing door on the "yellow storage" room across from Operating Room #3 would not engage the locking mechanism and remain closed and latched.
At 3:05 p.m., the cross corridor smoke doors on the 2nd floor near the entrance to Cardio Intensive Care near rooms #255-274 had unrepaired holes that penetrated the doors from old equipment that had been removed.
On November 9th, 2011 at 2:27 p.m., the door at PACS Administration storage was observed to lack the required self-closing device on the door that opens to a corridor.
Interview with the director of maintenance and the administrator at 4 p.m. on November 9th during the closing conference re-confirmed this finding.

Based on observation and interviews during the November 8th and 9th, 2011 survey, the facility failed to maintain the electrical supply/distribution system in compliance with the requirements of the Code. Per NFPA 70 (NEC) and NFPA 101 Ch. 9.1.2., "Electrical wiring and equipment shall be in accordance with NFPA 70. . . ." Additionally, NFPA 99 Ch. 8.5.2.2.1 specifies "A scheduled preventative maintenance program shall be followed." Additionally, NFPA 99, 9-2.1.2.2 specifies that "Material and gauge . . . .of electrical wiring/protection shall be a type suitable for the particular application."
Findings include:

During the building survey, along with the maintenance director and the administrator on November 8, 2011, the following non-conforming conditions of the electrical distribution system and the use of electrical appliances were observed.
1. At 9:45 a.m. in the physical therapy building (611) in the electrical room, circuit panels PNL L1 and L2 were observed to have spare circuit breakers in the "on" position.

2. At 10:12 a.m. in the Osceola Imaging Center building (730) in the electrical room, a large amount of boxed storage was observed to block access to the circuit breaker panels.

3. At 11 a.m. on the 4th floor break room, a residential type toaster was observed to be in contact with combustibles stored on a table in close proximity to a bulletin board.

4. At 11:25 a.m. in the 2nd floor anesthesia office, electrical devices were connected with a three prong adaptor that was connected to a power strip.

5. At 11:30 a.m. in the sub-sterile area of the 2nd floor operating room (OR), a freezer and a refrigerator were observed to be connected to the wall outlet with a power strip.

6. At 11:45 a.m. on the third floor in OR #2, a damaged electrical cord on patient care equipment (anesthesia) was observed to be loose and the insulation was worn and abraded near the plug.

7. At 2:05 p.m. in the Blood Bank area of the lab, in several instances, motorized electrical equipment was connected to the buildings power supply through the use of power strips connected in series with other power strips and extension cords.

8. At 2:10 p.m., on the first floor coffee vendor's area, electrical equipment was connected through ungrounded extension cords.

9. At 2:15 p.m., in the ER/ED, near the nurse's station, two power strips were connected in series to the wall outlet providing electrical power to several devices.

At 2:27 p.m., a microwave oven was observed to be connected to the wall outlet in the MRI staff break room.

At 2:35 p.m., several large imaging and patient treatment machines were observed in the Nuclear Medicine area. It was discovered that they were being provided with electrical power through at least two quad outlet boxes that were on the floor near the door. The quad boxes were not hospital grade and appeared to be assembled from non-conforming materials and lacked the features necessary to prevent damage to the equipment or that would provide protection from electric shock to staff, patients and the public.

Note: It is recommended that a thorough evaluation of the buildings electrical distribution system be undertaken to ensure that sufficient electrical outlets are provided where they are needed. The power for electrical equipment is required by code to be provided through a system that is in compliance.

These findings were re-confirmed with the administrator during the exit conference conference at 4 pm on November 9, 2011.

Based on observation and interviews with the maintenance director, the facility failed to maintain fire protection and occupant safety features necessary to minimize the spread of fire and the products of combustion areas of the building occupied by patients, staff and the public. The facility did not maintain the firestopping required for penetrations in rated assemblies. Per NFPA 101 Ch. 8.3.5.1, "Penetrations for cables, cable trays, conduits, pipes, tubes combustion vents . . . .and similar items. . . .that pass through a wall, floor, ceiling or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. . . ."
Findings are:
During the Life Safety Survey on November 8 and 9th, 2011 with the maintenance director we gained access to the CPCU communications closet and observed the following condition that would allow smoke and fire to enter the occupied space above.
At 1:55 p.m., November 9th, the floor/ceiling assembly was inspected and it was discovered that holes were drilled through the floor/ceiling to install electrical conduit from the equipment located in the room. The penetrations became un-sealed by an approved firestopping device or method when the fire caulk fell out of the metal sleeve installed for passing wires through the openings. Additionally, the annular spaces around the metal sleeves were unsealed. This condition creates vertical openings in the rated assembly and will allow fire and heated gases to enter the occupied space above.
Note: It is recommended that all vertical penetrations be inspected by maintenance personnel throughout the facility and sealed with an approved firestopping method.
These findings were re-confirmed during the exit conference with the Administrator at 4:30 p.m. on November 9th, 2011.

Based on an observation and interviews, the facility failed to maintain construction, protection, and occupancy features necessary to minimize danger to life from smoke, fumes or panic should a fire or similar emergency occur. The facility failed to maintain existing fire protection and life safety features such as smoke and fire barriers per NFPA 101-2006 , 4.6.12.1-.4, "Features required by the Code...shall be thereafter permanently maintained." Three (3) out of 10 sampled smoke/fire barrier walls had unsealed penetrations.
This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants. Unsealed penetrations in rated walls did not demonstrate compliance with the code standard. It is required that breaches and penetrations of all fire/smoke barriers be appropriately repaired and the walls / ceilings brought back to their original fire rated integrity. This would then restrict the movement of fire and smoke and help to ensure the safety of occupants within the facility in a fire emergency. These penetrations must be resealed with an approved firestopping method on both sides of each penetration.

Findings are:

During the life safety tour and observations with the facilities supervisor on November 8th and 9th, 2011, the following walls were not maintained to limit the transfer of smoke/heated gases should a fire occur.
At 9:45 a.m. on November 8th, observed that the rated wall in the south corridor in the wound care area of the building had an unsealed penetration. Ceiling tiles were displaced to allow visualization of the smoke/fire barrier and an unsealed penetration was discovered.
At 11:15 a.m. on November 9th, 2011 the ceiling tiles were displaced near patient room #401 in order to observe the smoke/fire barrier wall. It was determined that a penetration through the wall was unsealed in a sleeve provided for electrical wiring.
At 11.30 a.m. on November 9th, 2011 the ceiling above the cross corridor fire doors was displaced to observe the smoke wall. It was discovered to have unsealed penetrations in the rated assembly.
These findings were re-confirmed with the facilities director during the closing conference at 4:30 p.m. on November 9th, 2011.
NOTE: These examples are not to be considered as the only penetrations of the building's fire/smoke barrier walls. A thorough inspection of each fire/smoke barrier must be made along the full length and height of each wall to ensure that all penetrations are found and properly sealed.

Based on observation, testing and interviews with the facility staff, the facility failed to maintain fire protection and occupancy features necessary to minimize danger to patients, staff and the public from fire, smoke and panic should a fire occur. The facility did not maintain doors sampled during the survey that are designed to separate hazardous areas. Testing revealed doors that would not close completely and latch or that lacked the required self-closing devices in several locations in the facility. NFPA 101-2006, 4.6.12.1 requires that features "shall be continuously maintained in in proper operating condition. . . ." Also per NFPA 101 2006, 19.3.2.1, "the area shall be separated from the other spaces by smoke-resistant partitions and doors. . . ." Lack of separation due to required door features could allow smoke and fire gasses to quickly spread in the event of a fire. Additionally, per Chapter 39.3.2.2, "Hazardous areas including, but not limited to, areas used for general storage. . . .shall be protected in accordance with Section 8.7." Per Section 8.7.1.1, "Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building. . . .shall be provided. . . ." by (1) "Enclosing the area with a fire barrier. . . .in accordance with Section 8.3."

Findings are:

During the life safety tour of the facility on November 8, 2011 with the director of maintenance, observed that the following doors would not function to limit the transfer of smoke and the products of combustion should a fire occur.

Observation and testing of the door to the storage/mechanical room near the pool in the 611 building, (physical therapy) at 9:45 a.m. revealed that the door lacked the required door closer. Interview with the maintenance director evidenced that the room has been used for storage for several months. Since the room is used for storage and is larger than 50 square feet in area, a closing mechanism is required by the code. Storage also included several containers of flammable liquids and pool chemicals. Flammable liquids are required to be contained by an approved type storage locker per NFPA 30.
At 10:30 a.m., in the wound care area of the building, the door to the soiled utility room did not feature the required self-closing mechanism.
At 1:50 pm testing revealed that the self-closing door on the "yellow storage" room across from Operating Room #3 would not engage the locking mechanism and remain closed and latched.
At 3:05 p.m., the cross corridor smoke doors on the 2nd floor near the entrance to Cardio Intensive Care near rooms #255-274 had unrepaired holes that penetrated the doors from old equipment that had been removed.
On November 9th, 2011 at 2:27 p.m., the door at PACS Administration storage was observed to lack the required self-closing device on the door that opens to a corridor.
Interview with the director of maintenance and the administrator at 4 p.m. on November 9th during the closing conference re-confirmed this finding.

Based on observation and interviews during the November 8th and 9th, 2011 survey, the facility failed to maintain the electrical supply/distribution system in compliance with the requirements of the Code. Per NFPA 70 (NEC) and NFPA 101 Ch. 9.1.2., "Electrical wiring and equipment shall be in accordance with NFPA 70. . . ." Additionally, NFPA 99 Ch. 8.5.2.2.1 specifies "A scheduled preventative maintenance program shall be followed." Additionally, NFPA 99, 9-2.1.2.2 specifies that "Material and gauge . . . .of electrical wiring/protection shall be a type suitable for the particular application."
Findings include:

During the building survey, along with the maintenance director and the administrator on November 8, 2011, the following non-conforming conditions of the electrical distribution system and the use of electrical appliances were observed.
1. At 9:45 a.m. in the physical therapy building (611) in the electrical room, circuit panels PNL L1 and L2 were observed to have spare circuit breakers in the "on" position.

2. At 10:12 a.m. in the Osceola Imaging Center building (730) in the electrical room, a large amount of boxed storage was observed to block access to the circuit breaker panels.

3. At 11 a.m. on the 4th floor break room, a residential type toaster was observed to be in contact with combustibles stored on a table in close proximity to a bulletin board.

4. At 11:25 a.m. in the 2nd floor anesthesia office, electrical devices were connected with a three prong adaptor that was connected to a power strip.

5. At 11:30 a.m. in the sub-sterile area of the 2nd floor operating room (OR), a freezer and a refrigerator were observed to be connected to the wall outlet with a power strip.

6. At 11:45 a.m. on the third floor in OR #2, a damaged electrical cord on patient care equipment (anesthesia) was observed to be loose and the insulation was worn and abraded near the plug.

7. At 2:05 p.m. in the Blood Bank area of the lab, in several instances, motorized electrical equipment was connected to the buildings power supply through the use of power strips connected in series with other power strips and extension cords.

8. At 2:10 p.m., on the first floor coffee vendor's area, electrical equipment was connected through ungrounded extension cords.

9. At 2:15 p.m., in the ER/ED, near the nurse's station, two power strips were connected in series to the wall outlet providing electrical power to several devices.

At 2:27 p.m., a microwave oven was observed to be connected to the wall outlet in the MRI staff break room.

At 2:35 p.m., several large imaging and patient treatment machines were observed in the Nuclear Medicine area. It was discovered that they were being provided with electrical power through at least two quad outlet boxes that were on the floor near the door. The quad boxes were not hospital grade and appeared to be assembled from non-conforming materials and lacked the features necessary to prevent damage to the equipment or that would provide protection from electric shock to staff, patients and the public.

Note: It is recommended that a thorough evaluation of the buildings electrical distribution system be undertaken to ensure that sufficient electrical outlets are provided where they are needed. The power for electrical equipment is required by code to be provided through a system that is in compliance.

These findings were re-confirmed with the administrator during the exit conference conference at 4 pm on November 9, 2011.