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Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by an unsealed wall penetration. This affected 1 of 32 floors at the Main Campus. This could result in the passage of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception:* Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in.
(6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.

8.2.1* Construction. Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction
requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with staff members on 8/25/15, the walls and ceilings were observed.

Building C - 6th Floor

At 12:51 p.m., there was an approximately 4 inch by 5 inch penetration in the wall, in the Soiled Linen Utility Room 6C051.

Based on observation and interview, the facility failed to maintain its corridor doors. This was evidenced by corridor doors that failed to positive latch. This could result in the passage of smoke in the event of a fire and affected 2 of 32 floors at the Main Campus, and 1 of 5 floors at the Valley Specialty Center.

NFPA 101, Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

During a tour of the facility with staff members on 8/25/15, the corridor doors were observed.

Main Campus - Building M - 4th Floor

1. At 10:08 a.m., the door to Room 4M091 failed to latch when tested. When interviewed, Staff 1 stated the latching device was stuck.

2. At 10:15 a.m., the door to Room 4M075 failed to latch when tested. When interviewed, Staff 1 stated the latching device was stuck.

3. At 10:20 a.m., the door to Room 4M057 failed to latch when tested. When interviewed, Staff 1 stated the latching device was stuck.

Valley Specialty Center - 5th Floor

4. At 11:10 a.m., the door to Soiled Linen Utility Room 6C051 was equipped with a self-closing device. The door failed to positively latch when fully opened and released. Two attempts were made. When interviewed, Staff 1 stated the self-closing device needed adjustment.

Main Campus - Building C - 6th Floor

5. At 1:02 p.m., the door to Oxygen Room 6CJ01was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Staff 1 stated the self-closing device needed adjustment.

Based on observation, the facility failed to protect the hazardous areas. This was evidenced by a door to hazardous area that was not equipped with a self-closing device. This could result in the increased potential for the spread of fire and/or smoke to other areas of the facility and affected 1 of 32 floors at the Main Campus.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded
by a fire barrier having a 1-hour fire resistance rating
or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft 2 (9.3 m 2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft 2 (4.6 m 2), including
repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the
authority having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more
than 48 in. (122 cm) above the bottom of the door.

19.3.6.3 Corridor Door
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted
19.3.6.3.4 Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas
19.3.6.3.5 Nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted
19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

Findings:

During a tour of the facility with staff members on 8/25/15, the hazardous areas were observed.

Building C - 6th Floor

At 12:59 p.m., the door to the Oxygen Room 6C057 was not equipped with a self-closing device.

Based on observation and interview, the facility failed to maintain its automatic sprinkler system. This was evidenced by foreign material on sprinklers. This could result in an obstruction or malfunction of the automatic sprinkler system in the event of a fire. This affected 1 of 32 floors at the Main Campus.

NFPA 101 Life Safety Code, 2000 edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with staff members on 8/25/15, the automatic fire sprinkler system was observed.

Building K - 4th Floor

1. At 9:47 a.m., there was foreign material on a sprinkler in the corridor near Staff Lounge Room 4K075A. Staff members confirmed the finding and stated that the sprinkler would be cleaned.

2. At 9:50 a.m., there was foreign material on two of two sprinklers in the Nurse Station.

3. At 9:51 a.m., there was foreign material on a sprinkler head in the corridor near the Nurse Station. Staff members confirmed the finding and stated that the sprinkler would be cleaned.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by an unsealed wall penetration. This affected 1 of 32 floors at the Main Campus. This could result in the passage of smoke in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception:* Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in.
(6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.

8.2.1* Construction. Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction
requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided

8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) *Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with staff members on 8/25/15, the walls and ceilings were observed.

Building C - 6th Floor

At 12:51 p.m., there was an approximately 4 inch by 5 inch penetration in the wall, in the Soiled Linen Utility Room 6C051.

Based on observation and interview, the facility failed to maintain its corridor doors. This was evidenced by corridor doors that failed to positive latch. This could result in the passage of smoke in the event of a fire and affected 2 of 32 floors at the Main Campus, and 1 of 5 floors at the Valley Specialty Center.

NFPA 101, Life Safety Code, 2000 Edition
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

During a tour of the facility with staff members on 8/25/15, the corridor doors were observed.

Main Campus - Building M - 4th Floor

1. At 10:08 a.m., the door to Room 4M091 failed to latch when tested. When interviewed, Staff 1 stated the latching device was stuck.

2. At 10:15 a.m., the door to Room 4M075 failed to latch when tested. When interviewed, Staff 1 stated the latching device was stuck.

3. At 10:20 a.m., the door to Room 4M057 failed to latch when tested. When interviewed, Staff 1 stated the latching device was stuck.

Valley Specialty Center - 5th Floor

4. At 11:10 a.m., the door to Soiled Linen Utility Room 6C051 was equipped with a self-closing device. The door failed to positively latch when fully opened and released. Two attempts were made. When interviewed, Staff 1 stated the self-closing device needed adjustment.

Main Campus - Building C - 6th Floor

5. At 1:02 p.m., the door to Oxygen Room 6CJ01was equipped with a self-closing device. The door failed to positive latch when fully opened and released. When interviewed, Staff 1 stated the self-closing device needed adjustment.

Based on observation, the facility failed to protect the hazardous areas. This was evidenced by a door to hazardous area that was not equipped with a self-closing device. This could result in the increased potential for the spread of fire and/or smoke to other areas of the facility and affected 1 of 32 floors at the Main Campus.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded
by a fire barrier having a 1-hour fire resistance rating
or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft 2 (9.3 m 2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft 2 (4.6 m 2), including
repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the
authority having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more
than 48 in. (122 cm) above the bottom of the door.

19.3.6.3 Corridor Door
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted
19.3.6.3.4 Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas
19.3.6.3.5 Nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted
19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

Findings:

During a tour of the facility with staff members on 8/25/15, the hazardous areas were observed.

Building C - 6th Floor

At 12:59 p.m., the door to the Oxygen Room 6C057 was not equipped with a self-closing device.

Based on observation and interview, the facility failed to maintain its automatic sprinkler system. This was evidenced by foreign material on sprinklers. This could result in an obstruction or malfunction of the automatic sprinkler system in the event of a fire. This affected 1 of 32 floors at the Main Campus.

NFPA 101 Life Safety Code, 2000 edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with staff members on 8/25/15, the automatic fire sprinkler system was observed.

Building K - 4th Floor

1. At 9:47 a.m., there was foreign material on a sprinkler in the corridor near Staff Lounge Room 4K075A. Staff members confirmed the finding and stated that the sprinkler would be cleaned.

2. At 9:50 a.m., there was foreign material on two of two sprinklers in the Nurse Station.

3. At 9:51 a.m., there was foreign material on a sprinkler head in the corridor near the Nurse Station. Staff members confirmed the finding and stated that the sprinkler would be cleaned.