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Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.5.4
Based on observation and interview, the facility failed to protect vertical openings as required.

Findings include:

On 10/25/2011 at 8:00am, the Information technology closet on the 3rd floor was found to have 3 inch conduit in the ceiling that was not sealed to prevent the passage of smoke.

On 10/25/2011 at 8:10am, the Information technology room on the 3rd floor was found to have 3 inch and a 4 inch conduit in the ceiling that was not sealed to prevent the passage of smoke. Every floor is required to provide smoke compartmentation.

The facility manager acknowledged the finding when the deficiency was identified.

Failure to maintain smoke compartments increases the risk of death or injury due to fire.

The deficiency affected 2 of 5 smoke compartments.

Ref: 2000 NFPA 101 Section 39.3.1.1, 8.2.5.1

Based on observation and interview, the facility failed to protect stairway enclosures as required.

Findings include:

On 10/24/2011 at 3:40pm, the door to the west stairwell on the first floor was found to be equipped with panic hardware that was secured in the unlatched position. Fire exit hardware is required on fire doors so the doors always latch in the closed position.

Ref: 2000 NFPA 101 Section 19.2.1, 7.2.1.7.2,

On 10/24/2011 the left door on the second floor leading to the west stairwell was found to have a malfunctioning latch that did not secure the door in the closed position.

Ref: 2000 NFPA 101 8.1.1, 8.2.3.2.1; 1999 NFPA 80 Section 2-1.2, 2-1.4

On 10/24/2011 at 3:40pm, the door to the basement in the west stairwell on the first floor was found to have a closer that was disabled.

Ref: 2000 NFPA 101 Section 19.2.1, 7.1.3.2.1 (c)

The facility manager acknowledged the finding when the deficiency was identified.

Failure to protect exit stairways as required increases the risk of death or injury due to fire.

The deficiency affected 3 of 5 smoke compartments.

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 10/24/2011 at 3:15pm, slide bolts in addition to door knobs were found in use on two corridor doors to the pharmacy. The slide bolt would require a second motion to release the door. Doors in the means of egress are only permitted to have a single releasing motion.

The facility manager acknowledged the finding when the deficiency was identified.

Failure to provide latching devices as required increase the risk of death or injury due to fire.

The deficiency affected 1 of 5 smoke compartments.

Ref: 2000 NFPA 101 Section 39.2.2.2.1, 7.2.1.5.4

Based on observation and interview, the facility failed to provide a fire alarm system as required.

Findings include:

On 10/24/2011 a waiting area open to the corridor was found to not have smoke detection as provided in a fully detected facility.

The facility manager acknowledged the finding when the deficiency was identified.

Failure to provide smoke detection as required increases the risk of death or injury due to fire.

The deficiency affected 1 of 5 smoke compartments.

Ref: 2000 NFPA 101 Section 39.3.4.1, 4.6.12.2

Based on observation and interview, the facility failed to provide a fire extinguishing system as required.

Findings include:

On 10/24/2011 privacy curtains suspended at the ceiling in room 323 were found with a mesh in the upper 18 inches that consisted of a mesh of approximately 1/32 inch. This mesh would obstruct fire sprinkler spray.
The facility manager acknowledged the finding when the deficiency was identified.
Failure to insure sprinkler operation increases the risk of death or injury due to fire.
The deficiency affected 1 of 5 smoke compartments.
Ref: 2000 NFPA 101 Section 31.3.5.1, 9.7.1.1; 1999 NFPA 13 5-6.5.2.3

On 10/25/2011 sprinkler in the information technology room on the 3rd floor were found to be mounted in a sub ceiling 28 inches below the upper deck. 10 tiles were out missing from the sub ceiling rendering the upper deck the ceiling level. Standard pendant sprinklers are permitted to be mounted a maximum 12 inches below the ceiling.

The facility manager acknowledged the finding when the deficiency was identified.

Failure to install sprinklers as permitted increases the risk of death or injury due to fire.

The deficiency affected 1 of 5 smoke compartments.

Ref: 2000 NFPA 101 Section 31.3.5.1, 9.7.1.1; 1999 NFPA 13 5-6.4.1.1

Based on observation and interview, the facility failed to have on record a policy for interruption of service of the automatic sprinkler system for more than 4 hours in a 24 hour period where the AHJ would be notified and the building evacuated or a fire watch be put in place.

Findings include:

On 10/25/2011 at 11:00am, the facility policy on fire sprinkler interruption of service based did not contain the required notification of AHJ or evacuation or fire watch components.

The facility manager acknowledged the finding when the deficiency was identified.
Failure to provide a fire sprinkler outage policy as required increases the risk of death or injury due to fire.
The deficiency affected 5 of 5 smoke compartments.
Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.6.1

Based on observation and interview, the facility failed to have on record a policy for interruption of service of the fire alarm system for more than 4 hours in a 24 hour period where the AHJ would be notified and the building evacuated or a fire watch be put in place.

Findings include:

On 10/25/2011 at 11:00am, the facility policy on fire alarm interruption of service based did not contain the required notifications of AHJ or evacuation or fire watch components.

The facility manager acknowledged the finding when the deficiency was identified.

Failure to provide a fire alarm outage policy as required increases the risk of death or injury due to fire.

The deficiency affected 5 of 5 smoke compartments.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.8