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Based on observation and staff interview, an opening in the floor/ceiling separation failed to be maintained to resist the passage of smoke and fire. This condition would allow smoke and fire to migrate to other areas of the facility. Facility census was 90.

Findings are:
Observation during the facility tour on 11/13/14, at 11:20 am revealed a drain pipe penetrated the 3rd Floor Deck, and failed to be sealed to maintain the vertical fire separation.
In an interview conducted at the time of observation, (11/13/14, at 11:20 am), Safety A confirmed the penetration failed to be sealed.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, from 1:32 pm to 11/17/14, at 12:26 pm revealed:
1. An exit sign failed to be visible in the corridor on the 1st Floor by Room 1036 when the smoke doors closed.
2. The right chevron on the exit sign above the 1st Floor South Stair Tower Door was visible, and directed occupants in a direction that was not the exit. The exit sign failed to direct occupants straight ahead through the actual exit door.
In an interview conducted at the time of observations (11/13/14, from 1:32 pm to 11/17/14, at 12:26 pm), Safety A acknowledged the findings.

Based on observation and staff interview, the facility failed to seal a smoke barrier penetration. This condition had the potential to allow smoke to migrate between smoke compartments. Facility census was 90.

Findings are:
Observation above ceiling during the facility tour on 11/13/14, at 12:02 pm revealed holes around conduits in the 7th Floor West Hall Smoke Barrier outside of the Nurse Station failed to be sealed.
In an interview conducted at the time of observation, (11/13/14, at 12:02 pm), Safety A confirmed the penetrations in the barrier walls.

Based on observation and staff interview, the facility failed to provide smoke compartment doors that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, at 3:39 pm revealed a gap between the meeting edges of the smoke doors by Room 1542 failed to be sealed so as to resist the passage of smoke.
In an interview conducted at the time of observations (11/13/14, at 3:39 pm), Safety A confirmed the gap between the doors.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, from 9:37 am to 11/17/14, at 11:38 am revealed:
1. Two holes in the 7th Floor Environmental Services 18 wall failed to be sealed.
2. Gaps between the sheetrock and the deck failed to be sealed in the 1st Floor Lab Storage Room.
3. Holes around pipes in the southeast corner of the wall in the Boiler Room near the ceiling failed to be sealed.
In an interview conducted at the time of observations (11/13/14, from 9:37 am to 11/17/14, at 11:38 am), Safety A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain a set of doors in a horizontal exit to resist the passage of smoke and fire. This condition would allow smoke and fire to migrate to other areas of the facility. Facility census was 90.

Findings are:
Observation during the facility tour on 11/13/14, at 3:27 pm revealed the fire doors across from 1019 Nuclear Medication failed to latch when auto-closed.
In an interview conducted at the time of observation, (11/13/14, at 3:27 pm), Safety A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain an internally illuminated exit sign. This condition had the potential for staff to not recognize an exit during an emergency. Facility census was 90.

Findings are:
Observation during the facility tour on 11/13/14, at 10:09 am revealed the exit sign outside of Room 624 on the 6th Floor failed to be internally illuminated.
In an interview conducted at the time of observation, (11/13/14, at 10:09 am), Safety A acknowledged that the exit sign failed to be illuminated.

Based on observation and staff interview, the facility failed to provide sprinkler protection in all required areas. This condition would prevent a fire from being suppressed by the sprinkler system. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, at 3:08 pm revealed sprinkler protection failed to be installed under both overhead doors in the Loading Dock, so sprinkler coverage would be in place when the doors were raised.
In an interview conducted at the time of observations, (11/13/14, at 3:08 pm), Maintenance A confirmed the findings.

Actual NFPA Standard:
NFPA 13, 1999, 5-5.5.3.1
Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association 13 and 25. This condition would prevent a fire from being suppressed by the sprinkler system. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, from 9:37 am to 2:33 pm revealed:
1. The sprinkler head in the 7th Floor Environmental Services failed to be installed at least one foot six inches away from the light fixture to prevent obstruction to the sprinkler head.
2. The sprinkler head between OR 5 and 6 was loaded with dust accumulation, and failed to be cleaned.
In an interview conducted at the time of observations, (11/13/14, from 9:37 am to 2:33 pm), Safety A confirmed the findings.

Actual NFPA Standard:
NFPA 13, 1999, 5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

NFPA 25, 1998, 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.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility.

Findings are:
Observations during the facility tour on 11/17/14, from 12:04 pm to 12:16 pm revealed:
1. The MRI/CT Waiting Area Soiled Utility Room Door failed to self-close.
2. The Mamo Dressing Area Soiled Utility Room Door failed to self-close.
In an interview conducted at the time of observations (11/17/14, from 12:04 pm to 12:16 pm), Safety A acknowledged the findings.

NFPA 101, 2000, 38.3.2.1*
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

K130A

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler protection in all areas. This condition would prevent a fire from being suppressed by the sprinkler system. Facility census was 90.

Findings are:
Observations during the facility tour on 11/17/14, from 9:26 am to 9:53 am revealed:
1. The East Shelf in Biomed failed to be at least 18 inches below the sprinkler head. The back of the shelf obstructed sprinkler protection, and the area behind the shelf failed to be provided with sprinkler coverage.
2. A data cable failed to be installed so it was not fastened to the sprinkler pipe in the Lower Level EVS 155 Closet
In an interview conducted at the time of observations, (11/17/14, from 9:26 am to 9:53 am), Safety A confirmed the findings.

Actual NFPA Standard:
NFPA 13, 1999, 5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
5-5.6* Clearance to Storage.
The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 13, 1999, 6-1.1.5*
Sprinkler piping or hangers shall not be used to support nonsystem components.

K130 B

Based on observation and staff interview, the facility failed to maintain a set of fire doors in fire wall that separated two different construction types. This condition would allow smoke and fire to migrate to other areas of the facility. Facility census was 90.

Findings are:
Observation during the facility tour on 11/17/14, at 9:32 am revealed the three-hour fire rated doors in the fire wall between the North Storage Room and Materials Management failed to latch when auto-closed. A cart was also stored in front of the doors, and prevented the doors from fully closing.
In an interview conducted at the time of observation, (11/17/14, at 9:32 am), Safety A confirmed the findings.

NFPA 101, 2000, 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.

K130C

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility. Facility census was 90.

Findings are:
Observations during the facility tour on 11/17/14, at 9:57 am revealed the Lower Level EVS Shredding Room Door failed to close or latch when self-closed.
In an interview conducted at the time of observations (11/17/14, at 9:57 am), Safety A acknowledged the findings.

NFPA 101, 2000, 38.3.2.1*
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

Based on record review and staff interview, the facility failed to conduct fire drills for the lab quarterly. This condition would not provide adequate training for staff to react in the event of a fire. Facility census was 90.

Findings are:
Record review on 11/12/14, at 3:15 pm revealed a full evacuation fire drill for the Lab was conducted on 10/3/14. This was the only fire drill for the Lab that was provided. Fire drills failed to be conducted quarterly.
In an interview conducted at the time of record review, (11/12/14, at 3:15 pm), Safety A acknowledged that only one fire drill was provided.

NFPA 99, 10-2.1.4.3*
Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70. This condition had the potential to start an electrical fire. Facility census was 90.

Findings are:
Observation during the facility tour on 11/13/14, from 9:50 am to 11/17/14, 11:48 am revealed:
1. The radio equipment in the 9th Floor Penthouse failed to be plugged in direct without the use of an extension cord in lieu of permanent wiring.
2. A junction box in Wire Closet 508 failed to have a cover installed over the box.
3. A mini refrigerator in Hastings Radiology 111 was plugged into a power strip, and failed to be plugged in directly to an outlet.
4. Power strips in the Pain Clinic Patient Room on the computer cart were daisy chained, and failed to be plugged in directly to an outlet.
5. A scanning machine and wheelchair in the Nuclear Medication area failed to be stored so the items would not block electrical panels.
6. A junction box in the Electrical Vault failed to have a cover installed over the box.
7. A junction box above the Surgery Double Doors failed to have a cover installed over the box.
In an interview conducted at the time of observation (11/13/14, from 9:50 am to 11/17/14, 11:48 am), Maintenance A acknowledged the findings.

Based on observation and staff interview, an opening in the floor/ceiling separation failed to be maintained to resist the passage of smoke and fire. This condition would allow smoke and fire to migrate to other areas of the facility. Facility census was 90.

Findings are:
Observation during the facility tour on 11/13/14, at 11:20 am revealed a drain pipe penetrated the 3rd Floor Deck, and failed to be sealed to maintain the vertical fire separation.
In an interview conducted at the time of observation, (11/13/14, at 11:20 am), Safety A confirmed the penetration failed to be sealed.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, from 1:32 pm to 11/17/14, at 12:26 pm revealed:
1. An exit sign failed to be visible in the corridor on the 1st Floor by Room 1036 when the smoke doors closed.
2. The right chevron on the exit sign above the 1st Floor South Stair Tower Door was visible, and directed occupants in a direction that was not the exit. The exit sign failed to direct occupants straight ahead through the actual exit door.
In an interview conducted at the time of observations (11/13/14, from 1:32 pm to 11/17/14, at 12:26 pm), Safety A acknowledged the findings.

Based on observation and staff interview, the facility failed to seal a smoke barrier penetration. This condition had the potential to allow smoke to migrate between smoke compartments. Facility census was 90.

Findings are:
Observation above ceiling during the facility tour on 11/13/14, at 12:02 pm revealed holes around conduits in the 7th Floor West Hall Smoke Barrier outside of the Nurse Station failed to be sealed.
In an interview conducted at the time of observation, (11/13/14, at 12:02 pm), Safety A confirmed the penetrations in the barrier walls.

Based on observation and staff interview, the facility failed to provide smoke compartment doors that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, at 3:39 pm revealed a gap between the meeting edges of the smoke doors by Room 1542 failed to be sealed so as to resist the passage of smoke.
In an interview conducted at the time of observations (11/13/14, at 3:39 pm), Safety A confirmed the gap between the doors.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, from 9:37 am to 11/17/14, at 11:38 am revealed:
1. Two holes in the 7th Floor Environmental Services 18 wall failed to be sealed.
2. Gaps between the sheetrock and the deck failed to be sealed in the 1st Floor Lab Storage Room.
3. Holes around pipes in the southeast corner of the wall in the Boiler Room near the ceiling failed to be sealed.
In an interview conducted at the time of observations (11/13/14, from 9:37 am to 11/17/14, at 11:38 am), Safety A acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain a set of doors in a horizontal exit to resist the passage of smoke and fire. This condition would allow smoke and fire to migrate to other areas of the facility. Facility census was 90.

Findings are:
Observation during the facility tour on 11/13/14, at 3:27 pm revealed the fire doors across from 1019 Nuclear Medication failed to latch when auto-closed.
In an interview conducted at the time of observation, (11/13/14, at 3:27 pm), Safety A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain an internally illuminated exit sign. This condition had the potential for staff to not recognize an exit during an emergency. Facility census was 90.

Findings are:
Observation during the facility tour on 11/13/14, at 10:09 am revealed the exit sign outside of Room 624 on the 6th Floor failed to be internally illuminated.
In an interview conducted at the time of observation, (11/13/14, at 10:09 am), Safety A acknowledged that the exit sign failed to be illuminated.

Based on observation and staff interview, the facility failed to provide sprinkler protection in all required areas. This condition would prevent a fire from being suppressed by the sprinkler system. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, at 3:08 pm revealed sprinkler protection failed to be installed under both overhead doors in the Loading Dock, so sprinkler coverage would be in place when the doors were raised.
In an interview conducted at the time of observations, (11/13/14, at 3:08 pm), Maintenance A confirmed the findings.

Actual NFPA Standard:
NFPA 13, 1999, 5-5.5.3.1
Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association 13 and 25. This condition would prevent a fire from being suppressed by the sprinkler system. Facility census was 90.

Findings are:
Observations during the facility tour on 11/13/14, from 9:37 am to 2:33 pm revealed:
1. The sprinkler head in the 7th Floor Environmental Services failed to be installed at least one foot six inches away from the light fixture to prevent obstruction to the sprinkler head.
2. The sprinkler head between OR 5 and 6 was loaded with dust accumulation, and failed to be cleaned.
In an interview conducted at the time of observations, (11/13/14, from 9:37 am to 2:33 pm), Safety A confirmed the findings.

Actual NFPA Standard:
NFPA 13, 1999, 5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

NFPA 25, 1998, 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.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility.

Findings are:
Observations during the facility tour on 11/17/14, from 12:04 pm to 12:16 pm revealed:
1. The MRI/CT Waiting Area Soiled Utility Room Door failed to self-close.
2. The Mamo Dressing Area Soiled Utility Room Door failed to self-close.
In an interview conducted at the time of observations (11/17/14, from 12:04 pm to 12:16 pm), Safety A acknowledged the findings.

NFPA 101, 2000, 38.3.2.1*
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

Based on record review and staff interview, the facility failed to have the fire alarm system maintained in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke.

Findings are:
Record review during the facility tour on 11/12/14, at 4:06 pm of fire alarm inspection reports revealed the fire alarm failed to be inspected semi-annually. The most recent inspection report available for review was dated 1/2/14.
In an interview conducted at the time of record review, (11/12/14, at 4:06 pm), Safety A confirmed the findings.

Actual NFPA Standard:
NFPA 72, 1999, Table 7-3.2 Testing Frequencies

K130A

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler protection in all areas. This condition would prevent a fire from being suppressed by the sprinkler system. Facility census was 90.

Findings are:
Observations during the facility tour on 11/17/14, from 9:26 am to 9:53 am revealed:
1. The East Shelf in Biomed failed to be at least 18 inches below the sprinkler head. The back of the shelf obstructed sprinkler protection, and the area behind the shelf failed to be provided with sprinkler coverage.
2. A data cable failed to be installed so it was not fastened to the sprinkler pipe in the Lower Level EVS 155 Closet
In an interview conducted at the time of observations, (11/17/14, from 9:26 am to 9:53 am), Safety A confirmed the findings.

Actual NFPA Standard:
NFPA 13, 1999, 5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
5-5.6* Clearance to Storage.
The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 13, 1999, 6-1.1.5*
Sprinkler piping or hangers shall not be used to support nonsystem components.

K130 B

Based on observation and staff interview, the facility failed to maintain a set of fire doors in fire wall that separated two different construction types. This condition would allow smoke and fire to migrate to other areas of the facility. Facility census was 90.

Findings are:
Observation during the facility tour on 11/17/14, at 9:32 am revealed the three-hour fire rated doors in the fire wall between the North Storage Room and Materials Management failed to latch when auto-closed. A cart was also stored in front of the doors, and prevented the doors from fully closing.
In an interview conducted at the time of observation, (11/17/14, at 9:32 am), Safety A confirmed the findings.

NFPA 101, 2000, 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.

K130C

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas. This condition had the potential to allow smoke and fire to migrate into other areas of the facility. Facility census was 90.

Findings are:
Observations during the facility tour on 11/17/14, at 9:57 am revealed the Lower Level EVS Shredding Room Door failed to close or latch when self-closed.
In an interview conducted at the time of observations (11/17/14, at 9:57 am), Safety A acknowledged the findings.

NFPA 101, 2000, 38.3.2.1*
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70. This condition had the potential to start an electrical fire. Facility census was 90.

Findings are:
Observation during the facility tour on 11/13/14, from 9:50 am to 11/17/14, 11:48 am revealed:
1. The radio equipment in the 9th Floor Penthouse failed to be plugged in direct without the use of an extension cord in lieu of permanent wiring.
2. A junction box in Wire Closet 508 failed to have a cover installed over the box.
3. A mini refrigerator in Hastings Radiology 111 was plugged into a power strip, and failed to be plugged in directly to an outlet.
4. Power strips in the Pain Clinic Patient Room on the computer cart were daisy chained, and failed to be plugged in directly to an outlet.
5. A scanning machine and wheelchair in the Nuclear Medication area failed to be stored so the items would not block electrical panels.
6. A junction box in the Electrical Vault failed to have a cover installed over the box.
7. A junction box above the Surgery Double Doors failed to have a cover installed over the box.
In an interview conducted at the time of observation (11/13/14, from 9:50 am to 11/17/14, 11:48 am), Maintenance A acknowledged the findings.