HospitalInspections.org

Based upon observations hazardous areas are not maintained to provide required separation and or fire resistant ratings for the hazardous areas.

Findings Include:

On 09-06-2012 at 11:07 a.m. it is observed that rooms K-321-C and K-321-D are required to be constructed with 1 hour fire rated barrier walls. This is also indicated on the hospitals rated walls floor plan book. However, the walls fail to comply with the requirement as the walls are not continuous to the ceiling pan and stop just above the acoustical ceiling tile assembly.

BUSINESS OCCUPANCY
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain proper use of extension cords and power taps. This violation could affect up to 100% of the ten suite occupants on the second floor.
Survey findings include:
On 9-4-12 at approximately 1030 hours, it was revealed by observation that an extension cord was plugged into two power taps. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain proper use of extension cords and power taps. This violation could affect up to 100% of the ten suite occupants on the second floor.
Survey findings include:
On 9-4-12 at approximately 1030 hours, it was revealed by observation that an extension cord was plugged into two power taps. The Clinic Director confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain a proper fire evacuation plan. This violation could affect up to 100% of the ten suite occupants on the second floor.
Survey findings include:
On 9-4-12 at approximately 1035 hours, it was revealed by observation that the fire evacuation map posted on the wall was not accurate and did not reflect the evacuation plan that was practiced. Also, no manual pull stations were included. The Clinic Director confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the exit sign by the stairs. This violation affected the entire second floor since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 1040 hours, it was revealed by observation that the exit sign was not working by the second floor exit stair. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain complete fire drill reports. This violation could affect up to 100% of the ten suite occupants on the second floor.
Survey findings include:
On 9-4-12 at approximately 1045 hours, it was revealed by interview and observation that the fire drill form does not contain adequate information. The Clinic Director confirmed this evidence.

BUSINESS OCCUPANCY
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain complete fire evacuation plans. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1125 hours, it was revealed by interview and observation that the fire evacuation plans does not contain fire alarm device locations and other information. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the fire rated partitions separating the Cancer Center from the corridor to the main hospital. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1130 hours, it was revealed by observation that there were penetrations of the fire rated partitions between the Cancer Center and the main hospital corridor. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the fire signage on a room were oxygen was stored. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1140 hours, it was revealed by observation that there was a room containing compressed oxygen gas, but he door to the room was not marked indicating the hazard. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to remove combustibles from the corridor. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1145 hours, it was revealed by observation that several large three foot or more diameter flower pots in various locations in the corridors contained thick layers of combustible moss. The Clinic Director confirmed this evidence.


K-130
Based on observation and interviews, it was revealed that the facility had failed to remove combustibles the large clinic space used as a storage room. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1150 hours, it was revealed by observation that a future treatment area was being used to store numerous cardboard boxes and equipment posing a fire hazard. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility did not have fire drill reports on site. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1155 hours, it was revealed by observation that there were no fire drill reports on site. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to remove combustible storage from the emergency egress stairway. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 910 hours, it was revealed by observation that there was combustible storage inside the stairway on the ground floor. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the exit sign light in the stairwell on the first floor. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 912 hours, it was revealed by observation that there the exit sign inside the stairway was not illuminated. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the ceiling tiles in the closet with the folding doors. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 914 hours, it was revealed by observation that the closet with the double folding doors had a missing ceiling tile on the right side. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the warning signage on the doors where compressed gas (oxygen) was stored. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 917 hours, it was revealed by observation and interviews that compressed gas (oxygen) was stored in the Recovery and Operation rooms, but there were no signs indicating this on the doors. The Nurse Manager confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the vacant physician office area free of combustible storage. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 915 hours, it was revealed by observation and interviews that three vacant physician office rooms are being used for storage of cardboard boxes and other combustibles. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain 18 inches of space between the bottom of the sprinkler defectors and the linen stored in the linen closet. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 918 hours, it was revealed by observation that the linen closet had linen storage within two inches of the sprinkler deflectors, which could prevent the sprinklers from operating properly. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the fire rated partitions in the horizontal exit corridor. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 920 hours, it was revealed by observation that the linen closet had linen storage within two inches of the sprinkler deflectors, which could prevent the sprinklers from operating properly. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the fire rated partitions in the horizontal exit corridor. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 920 hours, it was revealed by observation that there are multiple penetrations of the fire rated partitions in the horizontal exit leading from the stairway. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the sprinkler system with properly labeled identification signs. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 925 hours, it was revealed by observation that the sprinkler sign mounted on the movable ceiling tile for the control valve does not properly provide what area the control valve monitors which is necessary in an emergency situation. Also, the sprinkler control room doors do not have signs indicating that the sprinkler valves are there. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain proper access to the sprinkler system. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 930 hours, it was revealed by observation that the door to the sprinkler valve room was partially blocked by stored tables and not easily accessed. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to provide audible alarms in the suite, smoke detection at the fire alarm panel, annunciation of the fire alarm devices on the fire alarm panel, or signage for the fire alarm panel room. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 935 hours, it was revealed by observation that the door to the fire alarm panel room did not have a sign indicating it contained the fire alarm panel, then panel does not annunciate the location of the devices, and there were no audible alarms in the suite. The Nurse Manager confirmed this evidence.

BUSINESS OCCUPANCY

Findings Include:

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there are low voltage cables that are lying on sprinkler pipes and are not supported properly above ceiling on the second floor. Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is cardboard used under the supports of the caddy bar above the ceiling that supports the box for the exit lights on the second floor. Combustible material is located in a ceiling return air plenum. Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is a missing sprinkler escutcheon in storage room 1. Referenced by 9.7

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there are floor penetrations that are not fire safe to prevent hot gasses to pass from the first floor to the second floor in the TELECOM room by the northeast stairway on the second floor. 39.3.1.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is an open junction box above ceiling by on the second floor near northeast stair and low voltage cables are not supported properly. Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is paper backed insulation above the ceiling on the second floor. Combustible material is located in a ceiling return air plenum. Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that the east stairway door is not self closing and latching on the second floor. Referenced by 39.3.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there are painted sprinkler heads in the medicine closet across from the nurse ' s station in Virginia Diabetes and in closet by the restroom. Referenced by 9.7

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is no sign on the doors or next to the door noting that there is main sprinkler control valves located in the room in the parking deck doors. Referenced by Virginia Statewide Fire Prevention Code 509.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is low voltage cable is supported from the sprinkler pipe in the parking deck Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is clear working space in front of electrical panel ' s ok means in electrical panels that are not closed Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is combustible material stored in electrical room in the parking deck gas equipment stored in the electrical room Referenced by Virginia Statewide Fire Prevention Code 313.1

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are deadbolt locks on the door to room 120. Referenced by 39.2.2.2

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a plug strip that is plugged into another plug strip and not directly into a permanent receptacle in room 134 on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a gap around sprinkler heads near room 8137 on the eighth floor. Referenced by 11.8.2

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical junction boxes that have covers missing on the eighth floor in the room by the mail chute. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are penetrations in the room by the mail chute that are not fire stopped with a listed design and product on the eighth floor. Referenced by 39.3.1.1

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a missing light switch cover in the room by the mail chute on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that the light is not working in the room by the mail chute on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are penetrations in the floors above and below in the mechanical room that are not fire stopped with a listed design and product on the eighth floor. Referenced by 39.3.1.1

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a loose receptacle and the cover is missing in the mechanical room on the eighth floor. The receptacle is not of a grounding type. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a floor drain that is not connected and is open to the floor below in the mechanical room of the eighth floor. The opening is not fire stopped with a listed design and product or not connected to the drainage system. Referenced by 39.3.1.1

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical panels, disconnects that are not labeled noting the panel and disconnect designation. There are electrical panels that are not labeled noting what the breakers inside the panel ' s supplies power to and the locations of the devices served. The panels are located on the 8th floor in the electrical room, mechanical room and in the corridor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there e are cables, conduits, junction boxes, and wires that are not supported according to the National Electric Code NFPA 70 in the electrical room and mechanical room on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are openings and/or covers are missing to electrical boxes and one is covered with plastic in the mechanical room on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are junction box covers are missing in the electrical room on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is an electrical panel that has an opening where breakers are missing on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a sprinkler head obstructed by a wall near room 8111 b. Referenced by 11.8.2

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that the chart room does not have proper sprinkler coverage and cabinets are too tall to provide a clear distance of 18 inches below the sprinkler head deflector in the west wing of the 8th floor Referenced by 11.8.2


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical panels in corridor that were locked and could not open the panel door and screws were missing near the men ' s bathroom on the eighth floor. Referenced by 39.5.1

New BLD 17On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that are ceiling tiles that have openings in them in rooms 3110 and 3111 on the third floor. Referenced by 11.8.2

New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are deadbolt locks on multiple doors north wing on the third floor north wing. Referenced by 38.2.2.2

New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a string of temporary lighting in west mechanical on the third floor. Referenced by 38.5.1


New BLD 17On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are penetrations in the floors above and below in the mechanical room that is not fire stopped with a listed design and product on the third floor. Referenced by 38.3.1.1

New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical junction boxes that have openings and/or covers are missing, and there are exposed wires on the third floor in the electrical and mechanical rooms. Referenced by 38.5.1


New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are cables, conduits, junction boxes, and wires that are not supported according to the National Electric Code NFPA 70 in the electrical and mechanical room on the third floor. Referenced by 38.5.1


New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical panels, disconnects that are not labeled noting the panel and disconnect designation. There are electrical panels that are not labeled noting what the breakers inside the panel ' s supplies power to and the locations of the devices served
Lame electrical panels in west electrical room open junction boxes car stop penetrations in the floor use phone supportive table junction boxes sprinkler head too far below ceiling opening in main electrical panel no dead front cover. Referenced by 38.5.1


New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that the door to file room 347 is not self closing and latching on the third floor. Referenced by 38.3.2.2

BUSINESS OCCUPANCY

Based on observation during a survey conducted on 8/31/2012 this facility fails to comply with section 38.3.6.1, which requires that corridors be constructed as fire barriers and maintain a 1 hour resistance rating.. this condition exists throughout all exit access corridors.

Finding Include:

On 8/31/2012 at 1300 hours, it was observed that the corridors walls are only constructed to just beyond the drop in ceiling, and are not rated.


Based on observation during a survey conducted on 8/31/2012 this facility fails to comply with section 38.2.2.2.6 which requires that access control and delayed egress comply with section 7.2.1.6.

Findings Include:

On 8?31/2012 at 1325 hours it was observed that access control doors do not cut power to the magnetic locks when the exit button is pushed.

BUSINESS OCCUPANCY

Based on observation during a validation survey on 9/6/2012 at 10:30 a.m. this facility failed to maintain a means of egress free of all obstructions or impediments.

Findings Include:

It is observed on 09-06-2012 at 10:30 a.m. that medical and office equipment obstructed the means of egress on the 5th floor, in/near room K-511. Pursuant to section 38.2.1.1 and more specifically section 7.1.10.1 of the 2000 Ed. of the NFPA 101 LSC the facility failed to comply.

Based on observation during a validation survey on 9/3/2012 during the hours of 0900 through 1500 this facility failed to provide occupant sensors on the controlled egress doors in all applications where magnetic locks are used. Section 7.6.1.6.2

Findings include

It was observed in all locations during the hours of 0900-1500 that occupancy sensors are not present with access controlled magnetic door locking systems.

BUSINESS OCCUPANCY

Based upon observations the fire rated smoke barrier walls and ceilings have penetrations, joints and openings that are not fire stopped and could allow smoke to pass from one side of the smoke barrier to the other side.

Findings include:

On 09-04-2012 at 09:09 a.m. it is observed that there is a penetration in the wall in the data closet. This finding has the potential to affect 100% of the occupants at the facility.

On 09-04-2012 at 09:10 a.m. it is observed that there is a hole in the ceiling near the cover plate. This finding has the potential to affect 100% of the occupants at the facility.

On 09-04-2012 at 09:20 a.m. it is observed that in the closet next to room 128 there is unsealed penetrations in the ceiling. This finding has the potential to affect 100% of the occupants at the facility.

On 09-04-2012 at 09:23 a.m. it is observed that there is multiple penetrations and voids in the mechanical closet near room 138. This finding has the potential to affect 100% of the occupants at the facility.

On 09-04-2012 at 09:30 a.m. it is observed that there is multiple penetrations and voids in the walls and ceiling of the water heater closet near room 147. This finding has the potential to affect 100% of the occupants at the facility.


Based on observation, it was determined that the facility had failed to maintain proper use of extension cords and power taps.

Findings include:

On 09-04-2012 at 09:15 a.m. it is observed that there was a multiplug extension cord being utilized to power the TV in the waiting room. This finding has the potential to affect 100% of the occupants in the waiting room and the front office.

BUSINESS OCCUPANCY

Based upon observations the fire rated smoke barrier walls have penetrations, joints at top of wall, and openings that are not fire stopped and could allow smoke to pass from one side of the smoke barrier to the other side.

Findings include:

On 09-04-2012 at 10:30 a.m. it is observed that the 1 hour fire rated smoke barrier wall located near room 134 above the acoustical ceiling tiles has 3 unsealed penetrations. This finding has the potential to affect 100% of the occupants located within this smoke compartment.

On 09-04-2012 at 10:35 a.m. it is observed that the 1 hour fire rated smoke barrier wall located near room 136 above the acoustical ceiling tiles has multiple unsealed penetrations and voids. This finding has the potential to affect 100% of the occupants located within this smoke compartment.

Based on interviews of staff during a validation survey on 9/11/2012 between the hours of 0900 and 1500 the , 9 of 18 staff members interviewed were not capable of correctly responding to fire emergency questions listed in section 18.7.2..1..2..

Findings Include:

The following is a breakdown of results, by floor, for answering the fire safety questions listed in section 18.7.2.1.2:

Floor Passed Failed No RACE card
11 2 2 1
10 0 0 0
09 1 0 0
08 0 2 1
07 1 1 0
06 1 0 0
05 0 0 0
04 1 1 0
03 1 1 1
02 0 1 1
01 0 0 0
G 0 1 0
SB1 0 0 0
SB2 0 0 0

Also 5 staff members stated they had not received Fire extinguisher training in over a year.

Of those that did pass, only 2 people could answer the questions without reading a RACE card.

Based on observations it is determined that the facility is not in compliance in regards to the Means of Egress Reliability, pursuant to section 7.1.10.2.1 of the NFPA 101 LSC 2000 ed.

Findings Include:

On 09-05-2012 at 09:30 a.m. it is observed that the visibility of the exit door located in the exit corridor north of the kitchen near room 2045 is obscured by a painted mural. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. this finding has the potential to affect 100% of the occupants of the first floor.

Based upon observation, smoke/fire barrier doors are not properly sealing and positively latching.

Findings include:

On 09-11-2012 at 1:20 p.m. it is observed that the smoke/fire barrier doors located on the 5th floor near room 5-103 will not fully close and positively latch due to a hardware malfunction. This finding effects 100% of the occupants within this smoke compartment.

Based upon observations, all of the sprinkler heads located on the 5th floor require cleaning and maintenance.

Findings include:

On 09-11-2012 at between 1:00 p.m. and 2:00 p.m. it is observed that multiple sprinkler heads located throughout the 5th floor are corroded or have heavy dust/dirt accumulations. This finding effects 100% of all occupants on this floor.

Based on observations it is noted that pressurized gas cylinders are not properly secured.

Findings include:

On 09-11-2012 at 10:15 a.m. it is observed that 2 oxygen cylinders are sitting unsecured in the corridor hall near room 10-246.

Based upon observations the electrical systems and equipment is not being maintained.

Findings include:

At 10:20 a.m., on 09-11-2012, it is observed that there is a electrical junction box with exposed wiring located above the ceiling level near room 9-108.

Based upon observations of the the fire alarm system, there are areas where the fire alarm pull station is obstructed.

Findings include

On 09-11-2012 at 3:00 p.m., it is observed that there is a desk located in front of the fire alarm pull station at the exit discharge door from room G-C34, which obstructs access to the pull station.


Based upon observations double exit break out doors are obstructed by the level of the concrete sidewalk and prevent the doors from operating properly.

Findings Include:

On 09-11-2012 at 2:40 p.m. it is observed that the exterior exit break out doors located at the main ED/ambulance entrance/exit cannot open to full swing as the level of the concrete sidewalk obstructs their operation.

Based upon observations and interviews a portable space heater is being in a patient sleeping area.

Findings include:

On 09-11-2012 at 2:55 p.m. it is determined that ED staff is using a portable space heater in a patient sleeping area that is in close proximity to combustible materials. The portable heater is located in room G-249 and is a coil type that exceeds 200 watts.

Based upon observations smoke barrier doors on the 10th floor are not properly sealing and positively latching.

Findings include:

On 09-11-2012 at 1:25 p.m. it is observed that the double smoke/fire barrier doors located on the 10th floor near room 10-316 are not properly sealing.

On 09-11-2012 at 1:28 p.m. it is observed that the double smoke/fire barrier doors located on the 10th floor near room 10-329-a are not positively latching.

These findings effect 100% of the occupants within this smoke compartment and the adjoining smoke compartment.

Based upon observations the fire/smoke compartment doors do not meet the required fire resistance rating of the barrier assembly.

Findings include:

On 09-11-2012 at approximately 1:00 p.m. it is observed that the smoke compartment doors located near the south freight elevator on the 4th floor do not meet the 1.5 hour rating requirement as the opening is situated within a 2 hour fire/smoke rated barrier wall. This finding effects 100% of the occupants within this smoke compartment.

New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that the electrical panels in the east wing are not labeled noting what each breaker supplies power to. Referenced by 38.5.1


New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is no sign noting that there is a fire department hose connection in the cabinet on the fourth floor east wing. Referenced by Virginia Statewide Fire Prevention Code 509.1

New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is an open junction box east mechanical room and circulator pump electrical box not secured and there is a hole in it that is not closed on the 4th floor. Referenced by 38.5.1


New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a sprinkler head obstructed by duck work in east mechanical room on the fourth floor. Referenced by 11.8.2

Based upon observations hazardous areas are not maintained to provide required separation and or fire resistant ratings for the hazardous areas.

Findings Include:

On 09-06-2012 at 11:07 a.m. it is observed that rooms K-321-C and K-321-D are required to be constructed with 1 hour fire rated barrier walls. This is also indicated on the hospitals rated walls floor plan book. However, the walls fail to comply with the requirement as the walls are not continuous to the ceiling pan and stop just above the acoustical ceiling tile assembly.

BUSINESS OCCUPANCY
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain proper use of extension cords and power taps. This violation could affect up to 100% of the ten suite occupants on the second floor.
Survey findings include:
On 9-4-12 at approximately 1030 hours, it was revealed by observation that an extension cord was plugged into two power taps. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain proper use of extension cords and power taps. This violation could affect up to 100% of the ten suite occupants on the second floor.
Survey findings include:
On 9-4-12 at approximately 1030 hours, it was revealed by observation that an extension cord was plugged into two power taps. The Clinic Director confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain a proper fire evacuation plan. This violation could affect up to 100% of the ten suite occupants on the second floor.
Survey findings include:
On 9-4-12 at approximately 1035 hours, it was revealed by observation that the fire evacuation map posted on the wall was not accurate and did not reflect the evacuation plan that was practiced. Also, no manual pull stations were included. The Clinic Director confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the exit sign by the stairs. This violation affected the entire second floor since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 1040 hours, it was revealed by observation that the exit sign was not working by the second floor exit stair. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain complete fire drill reports. This violation could affect up to 100% of the ten suite occupants on the second floor.
Survey findings include:
On 9-4-12 at approximately 1045 hours, it was revealed by interview and observation that the fire drill form does not contain adequate information. The Clinic Director confirmed this evidence.

BUSINESS OCCUPANCY
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain complete fire evacuation plans. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1125 hours, it was revealed by interview and observation that the fire evacuation plans does not contain fire alarm device locations and other information. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the fire rated partitions separating the Cancer Center from the corridor to the main hospital. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1130 hours, it was revealed by observation that there were penetrations of the fire rated partitions between the Cancer Center and the main hospital corridor. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the fire signage on a room were oxygen was stored. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1140 hours, it was revealed by observation that there was a room containing compressed oxygen gas, but he door to the room was not marked indicating the hazard. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to remove combustibles from the corridor. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1145 hours, it was revealed by observation that several large three foot or more diameter flower pots in various locations in the corridors contained thick layers of combustible moss. The Clinic Director confirmed this evidence.


K-130
Based on observation and interviews, it was revealed that the facility had failed to remove combustibles the large clinic space used as a storage room. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1150 hours, it was revealed by observation that a future treatment area was being used to store numerous cardboard boxes and equipment posing a fire hazard. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility did not have fire drill reports on site. This violation could affect up to 100% of the Cancer Center occupants.
Survey findings include:
On 9-4-12 at approximately 1155 hours, it was revealed by observation that there were no fire drill reports on site. The Clinic Director confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to remove combustible storage from the emergency egress stairway. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 910 hours, it was revealed by observation that there was combustible storage inside the stairway on the ground floor. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the exit sign light in the stairwell on the first floor. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 912 hours, it was revealed by observation that there the exit sign inside the stairway was not illuminated. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the ceiling tiles in the closet with the folding doors. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 914 hours, it was revealed by observation that the closet with the double folding doors had a missing ceiling tile on the right side. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the warning signage on the doors where compressed gas (oxygen) was stored. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 917 hours, it was revealed by observation and interviews that compressed gas (oxygen) was stored in the Recovery and Operation rooms, but there were no signs indicating this on the doors. The Nurse Manager confirmed this evidence.

K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the vacant physician office area free of combustible storage. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 915 hours, it was revealed by observation and interviews that three vacant physician office rooms are being used for storage of cardboard boxes and other combustibles. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain 18 inches of space between the bottom of the sprinkler defectors and the linen stored in the linen closet. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 918 hours, it was revealed by observation that the linen closet had linen storage within two inches of the sprinkler deflectors, which could prevent the sprinklers from operating properly. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the fire rated partitions in the horizontal exit corridor. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 920 hours, it was revealed by observation that the linen closet had linen storage within two inches of the sprinkler deflectors, which could prevent the sprinklers from operating properly. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the fire rated partitions in the horizontal exit corridor. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 920 hours, it was revealed by observation that there are multiple penetrations of the fire rated partitions in the horizontal exit leading from the stairway. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain the sprinkler system with properly labeled identification signs. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 925 hours, it was revealed by observation that the sprinkler sign mounted on the movable ceiling tile for the control valve does not properly provide what area the control valve monitors which is necessary in an emergency situation. Also, the sprinkler control room doors do not have signs indicating that the sprinkler valves are there. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to maintain proper access to the sprinkler system. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 930 hours, it was revealed by observation that the door to the sprinkler valve room was partially blocked by stored tables and not easily accessed. The Nurse Manager confirmed this evidence.
K-130
Based on observation and interviews, it was revealed that the facility had failed to provide audible alarms in the suite, smoke detection at the fire alarm panel, annunciation of the fire alarm devices on the fire alarm panel, or signage for the fire alarm panel room. This violation affected the entire building since this is business use, and there are no smoke barrier walls to form smoke compartments.
Survey findings include:
On 9-4-12 at approximately 935 hours, it was revealed by observation that the door to the fire alarm panel room did not have a sign indicating it contained the fire alarm panel, then panel does not annunciate the location of the devices, and there were no audible alarms in the suite. The Nurse Manager confirmed this evidence.

BUSINESS OCCUPANCY

Findings Include:

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there are low voltage cables that are lying on sprinkler pipes and are not supported properly above ceiling on the second floor. Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is cardboard used under the supports of the caddy bar above the ceiling that supports the box for the exit lights on the second floor. Combustible material is located in a ceiling return air plenum. Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is a missing sprinkler escutcheon in storage room 1. Referenced by 9.7

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there are floor penetrations that are not fire safe to prevent hot gasses to pass from the first floor to the second floor in the TELECOM room by the northeast stairway on the second floor. 39.3.1.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is an open junction box above ceiling by on the second floor near northeast stair and low voltage cables are not supported properly. Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is paper backed insulation above the ceiling on the second floor. Combustible material is located in a ceiling return air plenum. Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that the east stairway door is not self closing and latching on the second floor. Referenced by 39.3.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there are painted sprinkler heads in the medicine closet across from the nurse ' s station in Virginia Diabetes and in closet by the restroom. Referenced by 9.7

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is no sign on the doors or next to the door noting that there is main sprinkler control valves located in the room in the parking deck doors. Referenced by Virginia Statewide Fire Prevention Code 509.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is low voltage cable is supported from the sprinkler pipe in the parking deck Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is clear working space in front of electrical panel ' s ok means in electrical panels that are not closed Referenced by 39.5.1

On 9/13/2012 between 9:40 AM and 10:45 AM, it is observed that there is combustible material stored in electrical room in the parking deck gas equipment stored in the electrical room Referenced by Virginia Statewide Fire Prevention Code 313.1

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are deadbolt locks on the door to room 120. Referenced by 39.2.2.2

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a plug strip that is plugged into another plug strip and not directly into a permanent receptacle in room 134 on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a gap around sprinkler heads near room 8137 on the eighth floor. Referenced by 11.8.2

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical junction boxes that have covers missing on the eighth floor in the room by the mail chute. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are penetrations in the room by the mail chute that are not fire stopped with a listed design and product on the eighth floor. Referenced by 39.3.1.1

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a missing light switch cover in the room by the mail chute on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that the light is not working in the room by the mail chute on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are penetrations in the floors above and below in the mechanical room that are not fire stopped with a listed design and product on the eighth floor. Referenced by 39.3.1.1

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a loose receptacle and the cover is missing in the mechanical room on the eighth floor. The receptacle is not of a grounding type. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a floor drain that is not connected and is open to the floor below in the mechanical room of the eighth floor. The opening is not fire stopped with a listed design and product or not connected to the drainage system. Referenced by 39.3.1.1

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical panels, disconnects that are not labeled noting the panel and disconnect designation. There are electrical panels that are not labeled noting what the breakers inside the panel ' s supplies power to and the locations of the devices served. The panels are located on the 8th floor in the electrical room, mechanical room and in the corridor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there e are cables, conduits, junction boxes, and wires that are not supported according to the National Electric Code NFPA 70 in the electrical room and mechanical room on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are openings and/or covers are missing to electrical boxes and one is covered with plastic in the mechanical room on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are junction box covers are missing in the electrical room on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is an electrical panel that has an opening where breakers are missing on the eighth floor. Referenced by 39.5.1


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a sprinkler head obstructed by a wall near room 8111 b. Referenced by 11.8.2

Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that the chart room does not have proper sprinkler coverage and cabinets are too tall to provide a clear distance of 18 inches below the sprinkler head deflector in the west wing of the 8th floor Referenced by 11.8.2


Existing BLD 16 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical panels in corridor that were locked and could not open the panel door and screws were missing near the men ' s bathroom on the eighth floor. Referenced by 39.5.1

New BLD 17On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that are ceiling tiles that have openings in them in rooms 3110 and 3111 on the third floor. Referenced by 11.8.2

New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are deadbolt locks on multiple doors north wing on the third floor north wing. Referenced by 38.2.2.2

New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there is a string of temporary lighting in west mechanical on the third floor. Referenced by 38.5.1


New BLD 17On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are penetrations in the floors above and below in the mechanical room that is not fire stopped with a listed design and product on the third floor. Referenced by 38.3.1.1

New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical junction boxes that have openings and/or covers are missing, and there are exposed wires on the third floor in the electrical and mechanical rooms. Referenced by 38.5.1


New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are cables, conduits, junction boxes, and wires that are not supported according to the National Electric Code NFPA 70 in the electrical and mechanical room on the third floor. Referenced by 38.5.1


New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that there are electrical panels, disconnects that are not labeled noting the panel and disconnect designation. There are electrical panels that are not labeled noting what the breakers inside the panel ' s supplies power to and the locations of the devices served
Lame electrical panels in west electrical room open junction boxes car stop penetrations in the floor use phone supportive table junction boxes sprinkler head too far below ceiling opening in main electrical panel no dead front cover. Referenced by 38.5.1


New BLD 17 On 9/11/2012 between 1:40 PM and 3:30 PM, it is observed that the door to file room 347 is not self closing and latching on the third floor. Referenced by 38.3.2.2

BUSINESS OCCUPANCY

Based on observation during a survey conducted on 8/31/2012 this facility fails to comply with section 38.3.6.1, which requires that corridors be constructed as fire barriers and maintain a 1 hour resistance rating.. this condition exists throughout all exit access corridors.

Finding Include:

On 8/31/2012 at 1300 hours, it was observed that the corridors walls are only constructed to just beyond the drop in ceiling, and are not rated.


Based on observation during a survey conducted on 8/31/2012 this facility fails to comply with section 38.2.2.2.6 which requires that access control and delayed egress comply with section 7.2.1.6.

Findings Include:

On 8?31/2012 at 1325 hours it was observed that access control doors do not cut power to the magnetic locks when the exit button is pushed.

BUSINESS OCCUPANCY

Based on observation during a validation survey on 9/6/2012 at 10:30 a.m. this facility failed to maintain a means of egress free of all obstructions or impediments.

Findings Include:

It is observed on 09-06-2012 at 10:30 a.m. that medical and office equipment obstructed the means of egress on the 5th floor, in/near room K-511. Pursuant to section 38.2.1.1 and more specifically section 7.1.10.1 of the 2000 Ed. of the NFPA 101 LSC the facility failed to comply.

Based on observation during a validation survey on 9/3/2012 during the hours of 0900 through 1500 this facility failed to provide occupant sensors on the controlled egress doors in all applications where magnetic locks are used. Section 7.6.1.6.2

Findings include

It was observed in all locations during the hours of 0900-1500 that occupancy sensors are not present with access controlled magnetic door locking systems.

BUSINESS OCCUPANCY

Based upon observations the fire rated smoke barrier walls and ceilings have penetrations, joints and openings that are not fire stopped and could allow smoke to pass from one side of the smoke barrier to the other side.

Findings include:

On 09-04-2012 at 09:09 a.m. it is observed that there is a penetration in the wall in the data closet. This finding has the potential to affect 100% of the occupants at the facility.

On 09-04-2012 at 09:10 a.m. it is observed that there is a hole in the ceiling near the cover plate. This finding has the potential to affect 100% of the occupants at the facility.

On 09-04-2012 at 09:20 a.m. it is observed that in the closet next to room 128 there is unsealed penetrations in the ceiling. This finding has the potential to affect 100% of the occupants at the facility.

On 09-04-2012 at 09:23 a.m. it is observed that there is multiple penetrations and voids in the mechanical closet near room 138. This finding has the potential to affect 100% of the occupants at the facility.

On 09-04-2012 at 09:30 a.m. it is observed that there is multiple penetrations and voids in the walls and ceiling of the water heater closet near room 147. This finding has the potential to affect 100% of the occupants at the facility.


Based on observation, it was determined that the facility had failed to maintain proper use of extension cords and power taps.

Findings include:

On 09-04-2012 at 09:15 a.m. it is observed that there was a multiplug extension cord being utilized to power the TV in the waiting room. This finding has the potential to affect 100% of the occupants in the waiting room and the front office.

BUSINESS OCCUPANCY

Based upon observations the fire rated smoke barrier walls have penetrations, joints at top of wall, and openings that are not fire stopped and could allow smoke to pass from one side of the smoke barrier to the other side.

Findings include:

On 09-04-2012 at 10:30 a.m. it is observed that the 1 hour fire rated smoke barrier wall located near room 134 above the acoustical ceiling tiles has 3 unsealed penetrations. This finding has the potential to affect 100% of the occupants located within this smoke compartment.

On 09-04-2012 at 10:35 a.m. it is observed that the 1 hour fire rated smoke barrier wall located near room 136 above the acoustical ceiling tiles has multiple unsealed penetrations and voids. This finding has the potential to affect 100% of the occupants located within this smoke compartment.

Based on interviews of staff during a validation survey on 9/11/2012 between the hours of 0900 and 1500 the , 9 of 18 staff members interviewed were not capable of correctly responding to fire emergency questions listed in section 18.7.2..1..2..

Findings Include:

The following is a breakdown of results, by floor, for answering the fire safety questions listed in section 18.7.2.1.2:

Floor Passed Failed No RACE card
11 2 2 1
10 0 0 0
09 1 0 0
08 0 2 1
07 1 1 0
06 1 0 0
05 0 0 0
04 1 1 0
03 1 1 1
02 0 1 1
01 0 0 0
G 0 1 0
SB1 0 0 0
SB2 0 0 0

Also 5 staff members stated they had not received Fire extinguisher training in over a year.

Of those that did pass, only 2 people could answer the questions without reading a RACE card.

Based on observations it is determined that the facility is not in compliance in regards to the Means of Egress Reliability, pursuant to section 7.1.10.2.1 of the NFPA 101 LSC 2000 ed.

Findings Include:

On 09-05-2012 at 09:30 a.m. it is observed that the visibility of the exit door located in the exit corridor north of the kitchen near room 2045 is obscured by a painted mural. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. this finding has the potential to affect 100% of the occupants of the first floor.

Based upon observation, smoke/fire barrier doors are not properly sealing and positively latching.

Findings include:

On 09-11-2012 at 1:20 p.m. it is observed that the smoke/fire barrier doors located on the 5th floor near room 5-103 will not fully close and positively latch due to a hardware malfunction. This finding effects 100% of the occupants within this smoke compartment.

Based upon observations, all of the sprinkler heads located on the 5th floor require cleaning and maintenance.

Findings include:

On 09-11-2012 at between 1:00 p.m. and 2:00 p.m. it is observed that multiple sprinkler heads located throughout the 5th floor are corroded or have heavy dust/dirt accumulations. This finding effects 100% of all occupants on this floor.

Based on observations it is noted that pressurized gas cylinders are not properly secured.

Findings include:

On 09-11-2012 at 10:15 a.m. it is observed that 2 oxygen cylinders are sitting unsecured in the corridor hall near room 10-246.

Based upon observations the electrical systems and equipment is not being maintained.

Findings include:

At 10:20 a.m., on 09-11-2012, it is observed that there is a electrical junction box with exposed wiring located above the ceiling level near room 9-108.

Based upon observations of the the fire alarm system, there are areas where the fire alarm pull station is obstructed.

Findings include

On 09-11-2012 at 3:00 p.m., it is observed that there is a desk located in front of the fire alarm pull station at the exit discharge door from room G-C34, which obstructs access to the pull station.


Based upon observations double exit break out doors are obstructed by the level of the concrete sidewalk and prevent the doors from operating properly.

Findings Include:

On 09-11-2012 at 2:40 p.m. it is observed that the exterior exit break out doors located at the main ED/ambulance entrance/exit cannot open to full swing as the level of the concrete sidewalk obstructs their operation.

Based upon observations and interviews a portable space heater is being in a patient sleeping area.

Findings include:

On 09-11-2012 at 2:55 p.m. it is determined that ED staff is using a portable space heater in a patient sleeping area that is in close proximity to combustible materials. The portable heater is located in room G-249 and is a coil type that exceeds 200 watts.

Based upon observations smoke barrier doors on the 10th floor are not properly sealing and positively latching.

Findings include:

On 09-11-2012 at 1:25 p.m. it is observed that the double smoke/fire barrier doors located on the 10th floor near room 10-316 are not properly sealing.

On 09-11-2012 at 1:28 p.m. it is observed that the double smoke/fire barrier doors located on the 10th floor near room 10-329-a are not positively latching.

These findings effect 100% of the occupants within this smoke compartment and the adjoining smoke compartment.

Based upon observations the fire/smoke compartment doors do not meet the required fire resistance rating of the barrier assembly.

Findings include:

On 09-11-2012 at approximately 1:00 p.m. it is observed that the smoke compartment doors located near the south freight elevator on the 4th floor do not meet the 1.5 hour rating requirement as the opening is situated within a 2 hour fire/smoke rated barrier wall. This finding effects 100% of the occupants within this smoke compartment.