HospitalInspections.org

Based on observation it was discovered that the facility failed to properly maintain the corridor opening protection.

findings were

During the survey while accompanied by the Hospital Fire Marshal the following were observed
1) rags were stuffed into latch to keep it from properly latching at Rm. 5814
2) doors to Rms. 3927 & 1255 were found the doors would not latch

Based on observations it was discovered that the facility failed to properly maintain rated doorways


findings were

During the survey while accompanied by the Hospital Fire Marshal
1) the doors by Rm. 2383 has been field modified and may not be listed. it also stays in the open position an excessive amount of time.
2)Rm. 3154 hold open not working properly and found wedged open
3) double fire rated doors on 0 level to PCC do not close properly

Based on observation it was discovered that the facility failed to properly maintain the smoke barriers

findings were

During the survey while accompanied by the Hospital Fire Marshal
1) the smoke barrier by 7548 was found with many small holes thru the barrier
2) penetration in smoke barrier above ceiling at 4 E Family Lounge

Based on observations it was discovered that the facility failed to properly maintain the required separation from hazardous areas


findings were

On June 29, 2012 while accompanied by the Hospital Fire Marshal the following issues were observed

1) Oxygen storage room- fire rated roll-down door does not have required link or heat detector on both sides- only on the room side
2) By 1990 B the fire rated cross corridors doors did not close and latch properly
3) Rm. G 335 Main Electrical Distribution Room.-Fire Rated door does not close and latch properly
4) Rm. G 333 Main Fire Alarm Control Panel Room-Fire Rated door does not close and latch properly

Based on observation it was determined that the facility failed to properly maintain the fire rated walls that separate hazardous areas.


findings were

During the survey, while accompanied by the Hospital Fire Marshal the following were observed
1) penetration into fire rated wall in electrical rm. 7231,
2) door to soiled utility room 2947 will not close and latch
3) fire doors do not latch at Rms. 4202, 4502, 4242, 4504, and G 632

Based on observation it was discovered that the facility failed to properly maintain the separation between hazardous areas.

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal the following were observed

1) Rm. 225 unapproved material used to seal penetration in rated wall ( flammable spray expansion foam)
2) unsealed penetration above ceiling outside Rm. 106 of fire rated assembly
3) Rm. 104 rated fire doors has self closing device disconnected
4) elevator equipment room rated ceiling is not continuous to the wall-- not sealed in approved manner

Based on observations it was discovered that the facility failed to properly maintain the separation between hazardous areas and the rest of the structure.


findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal the required door closure was observed removed from the door to Rm. 1113, a storage room over 120 sq feet and an unseal penetration was found above ceiling in a fire rated wall in the same room

Based on observation it was discovered that the facility failed to properly maintain the means of egress


findings were

On June 29, 2012 while accompanied by the Hospital Maintenance Director.
3 Three of the marked exit doors were observed with unapproved deadbolts installed.

Based on observation it was discovered that the facility failed to maintain the egress in a proper manner.


findings were

On July 03, 2012 while accompanied by the Hospital Fire Marshal doors entering into the elevator lobby on the 3rd floor were found with magnetic locks and hold opens that were not properly installed per code to ensure exit access at all times. the security measures were installed at the UVA Medical Associates reception desks/offices so it could be secured but the area is in the second means of egress off this floor and half of the floor could be cut off from a second usable exit during an fire emergency

Based on observation it was discovered that the facility failed to properly maintain the exit signs.

findings were

During the survey while accompanied by the Hospital Fire Marshal the EXIT signs were found
1) with misleading directional arrows near Rms. 6125, 7136 and 5201.
2) Emergency EXIT sign directs occupant into construction area 3W ICU project
where the means of egress was not continuously maintained

Based on observation it was discovered that the new /existing fire alarm was not installed or maintained in accordance with NFPA 72

NOTE the facility is in the middle of a project to completely replace the existing fire alarm and detection system . The building was protected by one or both systems at all times thru the phased construction project



findings were
1) location of newly installed smoke detectors on walls are not with in the limites of 4 to 12 inches down from deck as per NFPA 72 section 2-3.4.3, were found in at least but not limited to:
6216, 5516, 5227,4516,4311 G 871 and on 2M near exit to stair #5

2) smoke detectors that had power cut to but not removed or tagged out of service were still installed in at least but not limited to
5197, 5198, 5174, 5111, 8180, 8186

3) open smoke detector base (base without smoke detector head installed ) of new fire alarm system found outside elevator #6 equipment rm reportedly not showing trouble on fire alarm control panel

Based on observation it was discovered that the facility failed to properly install or maintain the fire alarm system in accordance with NFPA 72

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal,

1) wall mounted smoke detector in Rm. 3314 was not in between the required distance of 4 and 12 inches down from deck
2) wall mounted smoke detector in Rm. 225 was not in between the required distance of 4 and 12 inches from deck

Based on observation it was discovered that the facility failed to properly maintain the sprinkler system


findings were

On June 29, 2012 , while accompanied by the Hospital Fire Marshal , the following were observed:

1) Penthouse- No hydraulic data plate was found posted for pre action system
2) Rm. 2081 -sprinkler pattern distrubution is obstructed by light fixture

Based on observation it was discovered that the facility failed to properly install or maintain the sprinkler system in accordance with NFPA 13. Although no requirements for sprinkler system in called for in a Business Use occupancy, when a system is installed it shall be installed per NFPA 13 and maintained per NFPA 25


findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal, the following issues were observed

1) Valley conference room- inadequate sprinkler coverage
2) corridor outside suite 102,-- two sprinkler escutcheons observed missing
3) Rm. 106 ( IT closet )-- sprinkler pattern obstructed by plastic placed on top of security cage
4) North Stairwell across from Rm. 111-- sprinkler head at bottom of stairwell still has shipping protective cap installed
5) Rm. 225- inadequate sprinkler coverage
6) second floor lobby storage room-- inadequate sprinkler coverage
7) Well Child play area-- inadequate sprinkler coverage around bulkhead area
8) Rm. 2245- sprinkler head placement more than 12 inches from deck
9) Rm. 2248 -storage within 18 inches of sprinkler head
10) at various locations thru out-- sprinkler pattern obstructed by "clouds", hanging shapes
11) outside Rm. 2233- there is no sprinkler coverage
12) outside Rm. 2221 at soffit- there is no sprinkler protection
13) Rm. 3314- sprinkler head placement more than 12 inches from deck
14) HOPE waiting Rm -no sprinkler protection near TV area

Based on observation it was discovered that the facility failed to properly maintain the sprinkler system

findings were

On July 03, 2012 while accompanied by the Hospital Fire Marshal
1) at least 2 sprinkler heads were observed painted inside the stairwell landing by Rm. 2400
2) sprinkler escushion cover was found missing in B 104 and 3701 (lab)

Based on observation it was discovered that the facility failed to properly maintain the sprinkler system in a code compliant manner.


finding were

During the survey while accompanied by the Hospital Fire Marshal, the following items in violation of NFPA 13 were observed.

1) hangers and sprinkler piping not self supported
a) one line of pipe attached to another sprinkler pipe above was found in stair #5 to heilo pad
b) by door# 2799 D (Link to PCC) where trapeze is hung from sprinkler line.
c) near 8506 , HVAC duct supported by sprinkler piping
d) 2M copper line attached in several places to sprinkler line near AHU-2M-6


2) improper coverage
a) sidewall type head in unapproved location at entrance to west penthouse by flammable cabinets
b) no sprinkler protection inside IRCA wall on floors 6 &7 East side near elevators
c) lack of complete sprinkler protection inside construction area in 5 East
d) lack of complete sprinkler protection inside constriction area 4602 (flex heads installed but not secured, no ceiling)
e) sprinkler head location in 3927 too far from deck
f) lack of complete sprinkler protection inside construction area 3 East
g) near Rm. 1836 sprinkler head over 15 feet from corridor end wall over newly created office/work space in the corridor

3) controls and trim
a) sprinkler head covers/ escutheon missing in at least but not limited to 7303, 5901, 4906, 4242 1843, 1763 B, 1601, 1466, G 513
b) sprinkler controls blocked in Rm. 1303
c) wrong escutheons installed on sprinkler heads near 1505 A&B
d) escutheon taped to ceiling in corridor near Rm. 5542

4) storage
a) excessive filter storage on 2M by AHU-2M-11 (blocks sprinkler coverage )
b) storage with in 18 inches of sprinkler head in Rms. 5114 &5115

Based on observation it was discovered that the facility failed to properly maintain the fire extinguishers in accordance with NFPA 10

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal, three fire extinguishers were found obstructed in the Social Services office, in the lobby, in the file room and in the storage closet.

Based on observation and conversations it was determined that the facility failed to properly maintain the cooking facilities ventilation systems


findings were

On June 25, 2012 while accompanied by the Hospital Fire Marshal the ventilation unit DX-P-1 in the penthouse was found dripping excessive amounts of grease from the seams. During conversations with the Facilities Management personal it was learned that this unit services the dishwasher area in the kitchen and had not been on a regular cleaning schedule as are all the other kitchen hoods.

Based on observations it was discovered that the facility failed to properly maintain the means of egress


findings were
On June 26, 2012 while accompanied by the Maintenance Director , the exit discharge from the control room to the public way had not been maintained or constructed in a proper way

Based on observation it was discovered that the facility failed to properly maintain the means of egress

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal, the marked EXIT door from the old section was observed with a prohibited dead bolt with thumb latch which could be locked and delay egress in time of emergency

Based on observations it was discovered that the facility failed to properly maintain the means of egress


findings were


During the survey while accompanied by the Hospital Fire Marshal the following were observed;

1) computers on wheels (COWS) were found "not in use", but stored, plugged into wall receptacles charging, in the corridors in at least but not limited to areas near Rms 8171, 8180, 8187,6113,6152,and 6148
2) hand rails were found loose near elevator #1 on 8 th floor
3) unattended room type trash can was found in corridor near Rm. 8152 B
4) exit door from East Penthouse sticks, hard to open
5) improper storage of items was found in corridor near Rm. 7238 and Rm. 6144
6) damaged door hardware was found on door to day room Rm. 7230
7) damaged hand rail was found near Rm. 7304 A
8) damaged door hardware was found on door to Rm. 2730
9) wheelchair left sitting in corridor at exit to ICU by Rm. 4248
10) recycling/storage in egress was observed in egress at nurses station 5 C

Based on observations it was discovered that the facility failed to properly maintain the piped in Medical Gases systems



findings were:

June 26, 2012 at 11:10 while accompanied by the Hospital Fire Marshal the piped in Medical Gas emergency shut off valves were observed blocked by storage in the West ICU near Rm. 6910

Based on observation it was discovered that the facility failed to properly maintain the facility in a safe and code compliant manner


findings were

On June 26, 2012 while accompanied by a representative of the UVA Medical Centers Maintenance Directors office, the following issues were observed

1)staff receptionist could not identify procedures to follow in case of fire
2)Fire Plans do not show required details of device locations
3)Fire Alarm smoke detector sensitivity test reports were not available at time of survey
4) Fire Alarm reports do not show horn strobe locations
5) 3rd floor stairwell # 3040 has improperly seal penetrations in rated walls
6) Near Rm. 3200 fire alarm strobe is loose on the wall
7) No records of annual fire alarm training as required
8)Rm. 3652 Electrical Rm has improperly sealed floor penetrations
9) 3650 hole in the north stairwell's rated wall above ceiling
10) Rm. 3163 clean utility room has open penetrations in rated walls( wire and Pipe openings)
11) Rm. 3163 smoke detector too close to air grill <3 feet
12) Rm. 3133 D -rated soiled utility room with open penetrations above ceiling and fire door does not latch
13) Rm. 2653 -electrical Rm. fire extinguisher is blocked by storage
14) Rm. 2317- sprinkler escutcheon plate was observed missing
15) Rm. 2207- smoke detector too close to air grill< 3 feet
16) stairs 2040 south end has penetrations above ceiling
17) Rm. 2047 sprinkler hydraulic data plate was observed missing
18) Rm. 1042 sprinkler escutcheon plate observed missing
19) 1041- elevator shaft has open penetrations in walls of rated shaft
20) Rm. 1506 A - electrical wiring observed running thru doorway( corrected during the survey )
21) Rm. 1506 A -storage was observed blocking electrical panel-( corrected during survey )
22) Rm. 1506 A -ceiling tiles observed missing
23) Rm. 1506 A- sprinkler escutcheon plate observed missing
24) Rm. 1312 -rated soiled utility room was observed with open penetration in rated walls
25) by 1410 EXIT sign does not work properly
26) by 1316 sprinkler escutcheon plate was observed missing
27) Rm. 3163 power strips were observed improperly connected in series at Residency Area
28) Rm. 3163- open penetration in rated walls above ceiling were observed
29) Rm. 2652 open penetrations was observed around pipe above ceiling
30) Rm. 2114 sprinkler escutcheon was observed missing
31) stairwell 2042 has open penetrations into rated stairwell wall
32) stairwell- gate to indicate discharge level was not working properly
33) Rm. 1506 D type breaker box was observed missing blind cap
34) Rm. 1122 B work station area was observed missing sprinkler escutcheon plate

Based on observation it was discovered that the facility failed to properly maintain the facility


findings were

On June 28, 2012 while accompanied by staff from the UVA Medical Centers Maintenance Directors office.

10 Third floor staff did not know where pull stations were located
2)Penetrations above stair exit door to 3rd floor by Suite 305 in rated enclosure
3) Rm. 3130- combustible storage and wood cabinets directly against hot water heater
4) Rm. 3130 open J box above ceiling
5) Rm. 3130- missing ceiling tile
6) by Rm. 3132 corridor fire extinguisher mounted too high
7) Rm. 3135 - storage too close to hot water heater
8) Suite 304 OBGYN office ceiling tile has excessive gaps around two sprinkler heads
9) Rm. 3062- electrical panel has openings, and incomplete panel schedule
10 ) Rm. 3062 has floor penetration not properly fire stopped in rated floor /ceiling assembly
11) Rm. 3201 - sprinkler escutcheon plate missing
12) Rm. 3020- Open holes in electrical receptacle
13) Rm. 3020- Fire Extinguisher improperly hung by hose
14) Rm. 3014 A storage too close to hot water heater , storage is also blocking the disconnect switch
15) Rm. 3022 roof access room- fire extinguisher not properly mounted
16) Rm. 3418 sprinkler escutcheon plate missing
17) Rm. 2014 storage too close to hot water heater and blocking disconnect switch
18) Community Medical area the staff did not know location of pull stations
19) Rm. 205 Internal Med, sprinkler head too far from door in corridor ( should be less than 7.5 feet )
20) 2nd floor ? Electrical room floor penetrations not properly fire stopped
21) Rm. 1062 electrical panel-- incomplete panel schedule
22) Rm. 1064- storage blocking access to sprinkler valves
23) Rm. 1064 and 1064 A sprinkler heads too far from ceiling ( should be less than 12 inches )
24) Rm. 1124 D sprinkler too close to wall alcove
25) no report on maintenance and testing of standpipes available at time of survey
26) rated corridor penetrations across from Rm. 1040 and in Rm 1040 not properly firestopped
27)Rm. 1014 A storage too close to hot water heater
28) Incomplete sprinkler coverage outside Rms. 1501, 1503 and 1403
29) Rm. 1041 three open j-unction boxes
30) Rm. 1041- storage less than 18 inches from sprinkler head
31) rated corridor near Rm. 1041 has several penetrations above ceiling not properly firestopped
32) rated corridor near Rm. 1041 has ceiling grid attached to sprinkler piping
33) 1st floor main lobby entrance way-- not proper coverage of sprinkler protection under the left side sitting area

Based onobservation it was discovered that the facility failed to properly maintain the facility



findings were

On June 26, 2012 while accompanied by a representative of the UVA Medical Center Maintenance Directors Office, the follow ing were observed

1) Rm. 3173 A -exit doorway was obstructed by desk
2) Hallway to Rm. 3100 C has penetrations in fire rated wall not properly firestoppped
3 )Building 3755 Elevator shaft has penetrations in rated walls on 1-3rd floors not firestopped
4) Rm. 1106 missing ceiling tiles
5) Rm. 1030- electrical rm has penetrations in fire rated wall not properly firestopped
6) Rm. 1030 sprinkler control room is being improperly used for storage which obstructs access to sprinkler system controls
7) Rm. 1030 has Refron Cylinders improperly stored
8) Rm. 3205- unapproved daisy chained power strips
9) Rm. 1013 penetrations in stairwell rated wall above ceiling not properly firestopped
10) Rm. 1010 ceiling tiles missing
11) 1021 penetrations above ceiling in rated wall not properly firestopped
12) Hallway near Rm. 1241 -EXIT sign not working properly when test button is pushed
13)Corridor near Rm. 1286- Large wheeled trash can full of combustibles left unattended in corridor

Based on observations it was discovered that the facility failed to properly maintain the back up electrical lighting system.




findings were

On June 25 while accompanied by the UVA Medical Center's Maintenance Director, the emergency lights in Rm. 1106 and Rm. 1048 were observed not to test properly

Based on observation it was discovered that the facility failed to properly maintain the electrical system and it's components


findings were
On June 29, 2012 while accompanied by the Hospital Fire Marshal
1) near Rm. 4100 (shell space)a electrical cord was found running under the door to an outlet on the other side of the wall, to charge a floor maintenance machine.
2) Electrical rooms not identified as such -3314, 3302, 2260, 2110, 2273, 1174 G 081, G 264
3) Rm. 2302 electrical wiring hanging from ceiling

Based on observation the facility failed to properly maintain or control the use of the electrical system and it's components.


findings were

During the survey while accompanied by the Hospital Fire Marshal the following were observed

1) computer on wheels was found at Rm. 7122 with power cords running thru the doorway to receptacle around corner, to charge, where cord is subject to damage by the door closing
2) nurse call light was observed hanging by wires near Rm. 8627
3) improper cart storage in front of electrical panel in Rm. 5487 B
4) power strips connected in series were found in the family lounge 4710
5) no panel schedule was available to sub panel LC3C in Rm. 3834
6) extension cord subject to damage found running under door to construction area from elevator lobby near 3694
7) excessive combustible storage was discovered in the electrical room 3789 A
8) no panel schedule was available to panel LLS-2C1 in Rm. 2939
9) GFI receptacle was found in Rm. 1018 with out cover plate
10) light fixture was found under dripping condensation from a unit above a dock area Rm. 6877
11) power strips connected in series were found in Rm. 6842
12) electrical room fire door does not latch at Rm. G 632

Based on observation it was discovered that the facility failed to properly maintain the electrical system


findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal , at the exterior rear of the building the lighting fixture was observed with exposed wiring.

Based on observation it was discovered that the facility failed to properly maintain the electrical system and it's components.

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal, the following were observed

1) HOPE electrical room not labeled as such
2)Rm. 221 work area-- an unapproved multi plug electrical adapter was found in use
3)Rm 104 -- combustible material stored on top of electrical equipment
4) Main electrical room and fire alarm panel room not labeled as such

Based on observation it was discovered that the facility failed to properly maintain the alcohol hand wash dispensers

finds were

On July 03, 2012 while accompanied by the Hospital Fire Marshal the hand wash dispensers were found in corridors less than 6 feet by 3114, 1422 and 1430.

Based on observation and interview it was discovered that the facility failed to properly maintain the Alcohol hand wash in a proper manner.

findings were

On July 3, 3012 while accompanied by the Hospital Fire Marshal the alcohol hand wash dispensers were found installed in corridors less than 6 feet in width near Rms. 1412, 1509 C and 1514.

Based on observation and record review it was discovered that the facility failed to properly control the use of alcohol hand wash


findings were

During the survey while accompanied by the Hospital Fire Marshal
1) the Hospital policy to control amount of product in fire areas was not followed in the part of the NICU Unit
2) dispenser was found installed in corridor less than 6 feet wide near Rm. 2230
3) dispenser was found in the Chapel lower than regulations allow
4) after market splash guards were installed under dispensers in the Radiology area in violation of Va. State Fire Code

Based on observation it was discovered that the facility failed to properly maintain the corridor opening protection.

findings were

During the survey while accompanied by the Hospital Fire Marshal the following were observed
1) rags were stuffed into latch to keep it from properly latching at Rm. 5814
2) doors to Rms. 3927 & 1255 were found the doors would not latch

Based on observations it was discovered that the facility failed to properly maintain rated doorways


findings were

During the survey while accompanied by the Hospital Fire Marshal
1) the doors by Rm. 2383 has been field modified and may not be listed. it also stays in the open position an excessive amount of time.
2)Rm. 3154 hold open not working properly and found wedged open
3) double fire rated doors on 0 level to PCC do not close properly

Based on observation it was discovered that the facility failed to properly maintain the smoke barriers

findings were

During the survey while accompanied by the Hospital Fire Marshal
1) the smoke barrier by 7548 was found with many small holes thru the barrier
2) penetration in smoke barrier above ceiling at 4 E Family Lounge

Based on observations it was discovered that the facility failed to properly maintain the required separation from hazardous areas


findings were

On June 29, 2012 while accompanied by the Hospital Fire Marshal the following issues were observed

1) Oxygen storage room- fire rated roll-down door does not have required link or heat detector on both sides- only on the room side
2) By 1990 B the fire rated cross corridors doors did not close and latch properly
3) Rm. G 335 Main Electrical Distribution Room.-Fire Rated door does not close and latch properly
4) Rm. G 333 Main Fire Alarm Control Panel Room-Fire Rated door does not close and latch properly

Based on observation it was determined that the facility failed to properly maintain the fire rated walls that separate hazardous areas.


findings were

During the survey, while accompanied by the Hospital Fire Marshal the following were observed
1) penetration into fire rated wall in electrical rm. 7231,
2) door to soiled utility room 2947 will not close and latch
3) fire doors do not latch at Rms. 4202, 4502, 4242, 4504, and G 632

Based on observation it was discovered that the facility failed to properly maintain the separation between hazardous areas.

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal the following were observed

1) Rm. 225 unapproved material used to seal penetration in rated wall ( flammable spray expansion foam)
2) unsealed penetration above ceiling outside Rm. 106 of fire rated assembly
3) Rm. 104 rated fire doors has self closing device disconnected
4) elevator equipment room rated ceiling is not continuous to the wall-- not sealed in approved manner

Based on observations it was discovered that the facility failed to properly maintain the separation between hazardous areas and the rest of the structure.


findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal the required door closure was observed removed from the door to Rm. 1113, a storage room over 120 sq feet and an unseal penetration was found above ceiling in a fire rated wall in the same room

Based on observation it was discovered that the facility failed to properly maintain the means of egress


findings were

On June 29, 2012 while accompanied by the Hospital Maintenance Director.
3 Three of the marked exit doors were observed with unapproved deadbolts installed.

Based on observation it was discovered that the facility failed to maintain the egress in a proper manner.


findings were

On July 03, 2012 while accompanied by the Hospital Fire Marshal doors entering into the elevator lobby on the 3rd floor were found with magnetic locks and hold opens that were not properly installed per code to ensure exit access at all times. the security measures were installed at the UVA Medical Associates reception desks/offices so it could be secured but the area is in the second means of egress off this floor and half of the floor could be cut off from a second usable exit during an fire emergency

Based on observation it was discovered that the facility failed to properly maintain the exit signs.

findings were

During the survey while accompanied by the Hospital Fire Marshal the EXIT signs were found
1) with misleading directional arrows near Rms. 6125, 7136 and 5201.
2) Emergency EXIT sign directs occupant into construction area 3W ICU project
where the means of egress was not continuously maintained

Based on observation it was discovered that the new /existing fire alarm was not installed or maintained in accordance with NFPA 72

NOTE the facility is in the middle of a project to completely replace the existing fire alarm and detection system . The building was protected by one or both systems at all times thru the phased construction project



findings were
1) location of newly installed smoke detectors on walls are not with in the limites of 4 to 12 inches down from deck as per NFPA 72 section 2-3.4.3, were found in at least but not limited to:
6216, 5516, 5227,4516,4311 G 871 and on 2M near exit to stair #5

2) smoke detectors that had power cut to but not removed or tagged out of service were still installed in at least but not limited to
5197, 5198, 5174, 5111, 8180, 8186

3) open smoke detector base (base without smoke detector head installed ) of new fire alarm system found outside elevator #6 equipment rm reportedly not showing trouble on fire alarm control panel

Based on observation it was discovered that the facility failed to properly install or maintain the fire alarm system in accordance with NFPA 72

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal,

1) wall mounted smoke detector in Rm. 3314 was not in between the required distance of 4 and 12 inches down from deck
2) wall mounted smoke detector in Rm. 225 was not in between the required distance of 4 and 12 inches from deck

Based on observation it was discovered that the facility failed to properly maintain the sprinkler system


findings were

On June 29, 2012 , while accompanied by the Hospital Fire Marshal , the following were observed:

1) Penthouse- No hydraulic data plate was found posted for pre action system
2) Rm. 2081 -sprinkler pattern distrubution is obstructed by light fixture

Based on observation it was discovered that the facility failed to properly install or maintain the sprinkler system in accordance with NFPA 13. Although no requirements for sprinkler system in called for in a Business Use occupancy, when a system is installed it shall be installed per NFPA 13 and maintained per NFPA 25


findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal, the following issues were observed

1) Valley conference room- inadequate sprinkler coverage
2) corridor outside suite 102,-- two sprinkler escutcheons observed missing
3) Rm. 106 ( IT closet )-- sprinkler pattern obstructed by plastic placed on top of security cage
4) North Stairwell across from Rm. 111-- sprinkler head at bottom of stairwell still has shipping protective cap installed
5) Rm. 225- inadequate sprinkler coverage
6) second floor lobby storage room-- inadequate sprinkler coverage
7) Well Child play area-- inadequate sprinkler coverage around bulkhead area
8) Rm. 2245- sprinkler head placement more than 12 inches from deck
9) Rm. 2248 -storage within 18 inches of sprinkler head
10) at various locations thru out-- sprinkler pattern obstructed by "clouds", hanging shapes
11) outside Rm. 2233- there is no sprinkler coverage
12) outside Rm. 2221 at soffit- there is no sprinkler protection
13) Rm. 3314- sprinkler head placement more than 12 inches from deck
14) HOPE waiting Rm -no sprinkler protection near TV area

Based on observation it was discovered that the facility failed to properly maintain the sprinkler system

findings were

On July 03, 2012 while accompanied by the Hospital Fire Marshal
1) at least 2 sprinkler heads were observed painted inside the stairwell landing by Rm. 2400
2) sprinkler escushion cover was found missing in B 104 and 3701 (lab)

Based on observation it was discovered that the facility failed to properly maintain the sprinkler system in a code compliant manner.


finding were

During the survey while accompanied by the Hospital Fire Marshal, the following items in violation of NFPA 13 were observed.

1) hangers and sprinkler piping not self supported
a) one line of pipe attached to another sprinkler pipe above was found in stair #5 to heilo pad
b) by door# 2799 D (Link to PCC) where trapeze is hung from sprinkler line.
c) near 8506 , HVAC duct supported by sprinkler piping
d) 2M copper line attached in several places to sprinkler line near AHU-2M-6


2) improper coverage
a) sidewall type head in unapproved location at entrance to west penthouse by flammable cabinets
b) no sprinkler protection inside IRCA wall on floors 6 &7 East side near elevators
c) lack of complete sprinkler protection inside construction area in 5 East
d) lack of complete sprinkler protection inside constriction area 4602 (flex heads installed but not secured, no ceiling)
e) sprinkler head location in 3927 too far from deck
f) lack of complete sprinkler protection inside construction area 3 East
g) near Rm. 1836 sprinkler head over 15 feet from corridor end wall over newly created office/work space in the corridor

3) controls and trim
a) sprinkler head covers/ escutheon missing in at least but not limited to 7303, 5901, 4906, 4242 1843, 1763 B, 1601, 1466, G 513
b) sprinkler controls blocked in Rm. 1303
c) wrong escutheons installed on sprinkler heads near 1505 A&B
d) escutheon taped to ceiling in corridor near Rm. 5542

4) storage
a) excessive filter storage on 2M by AHU-2M-11 (blocks sprinkler coverage )
b) storage with in 18 inches of sprinkler head in Rms. 5114 &5115

Based on observation it was discovered that the facility failed to properly maintain the fire extinguishers in accordance with NFPA 10

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal, three fire extinguishers were found obstructed in the Social Services office, in the lobby, in the file room and in the storage closet.

Based on observation and conversations it was determined that the facility failed to properly maintain the cooking facilities ventilation systems


findings were

On June 25, 2012 while accompanied by the Hospital Fire Marshal the ventilation unit DX-P-1 in the penthouse was found dripping excessive amounts of grease from the seams. During conversations with the Facilities Management personal it was learned that this unit services the dishwasher area in the kitchen and had not been on a regular cleaning schedule as are all the other kitchen hoods.

Based on observations it was discovered that the facility failed to properly maintain the means of egress


findings were
On June 26, 2012 while accompanied by the Maintenance Director , the exit discharge from the control room to the public way had not been maintained or constructed in a proper way

Based on observation it was discovered that the facility failed to properly maintain the means of egress

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal, the marked EXIT door from the old section was observed with a prohibited dead bolt with thumb latch which could be locked and delay egress in time of emergency

Based on observations it was discovered that the facility failed to properly maintain the means of egress


findings were


During the survey while accompanied by the Hospital Fire Marshal the following were observed;

1) computers on wheels (COWS) were found "not in use", but stored, plugged into wall receptacles charging, in the corridors in at least but not limited to areas near Rms 8171, 8180, 8187,6113,6152,and 6148
2) hand rails were found loose near elevator #1 on 8 th floor
3) unattended room type trash can was found in corridor near Rm. 8152 B
4) exit door from East Penthouse sticks, hard to open
5) improper storage of items was found in corridor near Rm. 7238 and Rm. 6144
6) damaged door hardware was found on door to day room Rm. 7230
7) damaged hand rail was found near Rm. 7304 A
8) damaged door hardware was found on door to Rm. 2730
9) wheelchair left sitting in corridor at exit to ICU by Rm. 4248
10) recycling/storage in egress was observed in egress at nurses station 5 C

Based on observations it was discovered that the facility failed to properly maintain the piped in Medical Gases systems



findings were:

June 26, 2012 at 11:10 while accompanied by the Hospital Fire Marshal the piped in Medical Gas emergency shut off valves were observed blocked by storage in the West ICU near Rm. 6910

Based on observation it was discovered that the facility failed to properly maintain the facility in a safe and code compliant manner


findings were

On June 26, 2012 while accompanied by a representative of the UVA Medical Centers Maintenance Directors office, the following issues were observed

1)staff receptionist could not identify procedures to follow in case of fire
2)Fire Plans do not show required details of device locations
3)Fire Alarm smoke detector sensitivity test reports were not available at time of survey
4) Fire Alarm reports do not show horn strobe locations
5) 3rd floor stairwell # 3040 has improperly seal penetrations in rated walls
6) Near Rm. 3200 fire alarm strobe is loose on the wall
7) No records of annual fire alarm training as required
8)Rm. 3652 Electrical Rm has improperly sealed floor penetrations
9) 3650 hole in the north stairwell's rated wall above ceiling
10) Rm. 3163 clean utility room has open penetrations in rated walls( wire and Pipe openings)
11) Rm. 3163 smoke detector too close to air grill <3 feet
12) Rm. 3133 D -rated soiled utility room with open penetrations above ceiling and fire door does not latch
13) Rm. 2653 -electrical Rm. fire extinguisher is blocked by storage
14) Rm. 2317- sprinkler escutcheon plate was observed missing
15) Rm. 2207- smoke detector too close to air grill< 3 feet
16) stairs 2040 south end has penetrations above ceiling
17) Rm. 2047 sprinkler hydraulic data plate was observed missing
18) Rm. 1042 sprinkler escutcheon plate observed missing
19) 1041- elevator shaft has open penetrations in walls of rated shaft
20) Rm. 1506 A - electrical wiring observed running thru doorway( corrected during the survey )
21) Rm. 1506 A -storage was observed blocking electrical panel-( corrected during survey )
22) Rm. 1506 A -ceiling tiles observed missing
23) Rm. 1506 A- sprinkler escutcheon plate observed missing
24) Rm. 1312 -rated soiled utility room was observed with open penetration in rated walls
25) by 1410 EXIT sign does not work properly
26) by 1316 sprinkler escutcheon plate was observed missing
27) Rm. 3163 power strips were observed improperly connected in series at Residency Area
28) Rm. 3163- open penetration in rated walls above ceiling were observed
29) Rm. 2652 open penetrations was observed around pipe above ceiling
30) Rm. 2114 sprinkler escutcheon was observed missing
31) stairwell 2042 has open penetrations into rated stairwell wall
32) stairwell- gate to indicate discharge level was not working properly
33) Rm. 1506 D type breaker box was observed missing blind cap
34) Rm. 1122 B work station area was observed missing sprinkler escutcheon plate

Based on observation it was discovered that the facility failed to properly maintain the facility


findings were

On June 28, 2012 while accompanied by staff from the UVA Medical Centers Maintenance Directors office.

10 Third floor staff did not know where pull stations were located
2)Penetrations above stair exit door to 3rd floor by Suite 305 in rated enclosure
3) Rm. 3130- combustible storage and wood cabinets directly against hot water heater
4) Rm. 3130 open J box above ceiling
5) Rm. 3130- missing ceiling tile
6) by Rm. 3132 corridor fire extinguisher mounted too high
7) Rm. 3135 - storage too close to hot water heater
8) Suite 304 OBGYN office ceiling tile has excessive gaps around two sprinkler heads
9) Rm. 3062- electrical panel has openings, and incomplete panel schedule
10 ) Rm. 3062 has floor penetration not properly fire stopped in rated floor /ceiling assembly
11) Rm. 3201 - sprinkler escutcheon plate missing
12) Rm. 3020- Open holes in electrical receptacle
13) Rm. 3020- Fire Extinguisher improperly hung by hose
14) Rm. 3014 A storage too close to hot water heater , storage is also blocking the disconnect switch
15) Rm. 3022 roof access room- fire extinguisher not properly mounted
16) Rm. 3418 sprinkler escutcheon plate missing
17) Rm. 2014 storage too close to hot water heater and blocking disconnect switch
18) Community Medical area the staff did not know location of pull stations
19) Rm. 205 Internal Med, sprinkler head too far from door in corridor ( should be less than 7.5 feet )
20) 2nd floor ? Electrical room floor penetrations not properly fire stopped
21) Rm. 1062 electrical panel-- incomplete panel schedule
22) Rm. 1064- storage blocking access to sprinkler valves
23) Rm. 1064 and 1064 A sprinkler heads too far from ceiling ( should be less than 12 inches )
24) Rm. 1124 D sprinkler too close to wall alcove
25) no report on maintenance and testing of standpipes available at time of survey
26) rated corridor penetrations across from Rm. 1040 and in Rm 1040 not properly firestopped
27)Rm. 1014 A storage too close to hot water heater
28) Incomplete sprinkler coverage outside Rms. 1501, 1503 and 1403
29) Rm. 1041 three open j-unction boxes
30) Rm. 1041- storage less than 18 inches from sprinkler head
31) rated corridor near Rm. 1041 has several penetrations above ceiling not properly firestopped
32) rated corridor near Rm. 1041 has ceiling grid attached to sprinkler piping
33) 1st floor main lobby entrance way-- not proper coverage of sprinkler protection under the left side sitting area

Based onobservation it was discovered that the facility failed to properly maintain the facility



findings were

On June 26, 2012 while accompanied by a representative of the UVA Medical Center Maintenance Directors Office, the follow ing were observed

1) Rm. 3173 A -exit doorway was obstructed by desk
2) Hallway to Rm. 3100 C has penetrations in fire rated wall not properly firestoppped
3 )Building 3755 Elevator shaft has penetrations in rated walls on 1-3rd floors not firestopped
4) Rm. 1106 missing ceiling tiles
5) Rm. 1030- electrical rm has penetrations in fire rated wall not properly firestopped
6) Rm. 1030 sprinkler control room is being improperly used for storage which obstructs access to sprinkler system controls
7) Rm. 1030 has Refron Cylinders improperly stored
8) Rm. 3205- unapproved daisy chained power strips
9) Rm. 1013 penetrations in stairwell rated wall above ceiling not properly firestopped
10) Rm. 1010 ceiling tiles missing
11) 1021 penetrations above ceiling in rated wall not properly firestopped
12) Hallway near Rm. 1241 -EXIT sign not working properly when test button is pushed
13)Corridor near Rm. 1286- Large wheeled trash can full of combustibles left unattended in corridor

Based on observations it was discovered that the facility failed to properly maintain the back up electrical lighting system.




findings were

On June 25 while accompanied by the UVA Medical Center's Maintenance Director, the emergency lights in Rm. 1106 and Rm. 1048 were observed not to test properly

Based on observation it was discovered that the facility failed to properly maintain the electrical system and it's components


findings were
On June 29, 2012 while accompanied by the Hospital Fire Marshal
1) near Rm. 4100 (shell space)a electrical cord was found running under the door to an outlet on the other side of the wall, to charge a floor maintenance machine.
2) Electrical rooms not identified as such -3314, 3302, 2260, 2110, 2273, 1174 G 081, G 264
3) Rm. 2302 electrical wiring hanging from ceiling

Based on observation the facility failed to properly maintain or control the use of the electrical system and it's components.


findings were

During the survey while accompanied by the Hospital Fire Marshal the following were observed

1) computer on wheels was found at Rm. 7122 with power cords running thru the doorway to receptacle around corner, to charge, where cord is subject to damage by the door closing
2) nurse call light was observed hanging by wires near Rm. 8627
3) improper cart storage in front of electrical panel in Rm. 5487 B
4) power strips connected in series were found in the family lounge 4710
5) no panel schedule was available to sub panel LC3C in Rm. 3834
6) extension cord subject to damage found running under door to construction area from elevator lobby near 3694
7) excessive combustible storage was discovered in the electrical room 3789 A
8) no panel schedule was available to panel LLS-2C1 in Rm. 2939
9) GFI receptacle was found in Rm. 1018 with out cover plate
10) light fixture was found under dripping condensation from a unit above a dock area Rm. 6877
11) power strips connected in series were found in Rm. 6842
12) electrical room fire door does not latch at Rm. G 632

Based on observation it was discovered that the facility failed to properly maintain the electrical system


findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal , at the exterior rear of the building the lighting fixture was observed with exposed wiring.

Based on observation it was discovered that the facility failed to properly maintain the electrical system and it's components.

findings were

On July 02, 2012 while accompanied by the Hospital Fire Marshal, the following were observed

1) HOPE electrical room not labeled as such
2)Rm. 221 work area-- an unapproved multi plug electrical adapter was found in use
3)Rm 104 -- combustible material stored on top of electrical equipment
4) Main electrical room and fire alarm panel room not labeled as such