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Based on observations and interview the facility failed to ensure that 1 soiled utility room is equipped with an automatic door closing device and 1 set of fire rated corridor doors could automatically close to a latched position.

Findings include:

Observations during tour on 12/13/17 between 11:45 a.m. and 12:30 p.m. with Staff A (Engineering Manager) revealed that the soiled utility room door, located on the 2nd floor of building 6, next to exam room # 5, had the required automatic door closing device removed from the door. The 1 set of 90 minute fire rated corridor doors, in the same location, failed to close to a fully latched position when released from the magnetic hold open device.

Interview with Staff A confirmed the findings and location. The automatic door closing device was reinstalled and the corridor fire doors were adjusted to be fully operational during tour..

NFPA 101 Life Safety Code (2012 edition)
8.3.1.2 Fire Barriers shall comply with one of the following:

(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
(2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier.

8.3.4 Opening Protective's

8.3.4.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.


Based on observations and interview the facility failed to ensure that 4 separate penetrations, through 2 hour fire wall's, were properly sealed to prevent the movement of smoke and the effects from fire.

Findings include:

Observations during tour on 12/13/17 between 8:30 a.m. and 12:30 p.m. with Staff A (Engineering Manager) and Staff B (Maintenance Personnel) revealed 4 fire barrier locations, above the suspended ceilings, which had unprotected penetrations through the fire barrier.
These locations are as follows:
1. Building # 1, Stairwell 1A, above the 2nd floor exit doorway has a portion of drywall (approximately 8" x 10") removed for electrical locking equipment and will not maintain the 2 hour fire barrier rating.
2. Building # 1, Stairwell 1A, above the 3rd floor exit doorway has a portion of drywall (approximately 8" x 8" ) removed for electrical locking equipment and will not maintain the 2 hour fire barrier rating.
3. Building # 1, Stairwell 1A, above the 4th floor exit doorway has a portion of drywall (approximately 8" x 8" ) removed for electrical locking equipment and will not maintain the 2 hour fire barrier rating.
4. Building # 1, In the utility corridor, above door # 120H01, has an unsealed penetration of a 3/4" electrical conduit and will not maintain the 2 hour fire barrier rating.

Interview with Staff A and Staff B confirmed the findings and locations.
These penetrations were repaired and inspected before the conclusion of this survey.