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Based upon observations the fire rated walls that are not constructed to maintain the required fire resistance rating.

Findings include

On 10/24/14 around 9:05 AM it is observed that there is a fire rated wall that is not installed according the listed design at inpatient rehabilitation on the fourth floor.

On 10/24/14 around 9:15 AM it is observed that there is exposed combustible foam board at the north side behind the wall on near inpatient rehabilitation on the fourth floor.


30721

Based on observations the facility failed to properly maintain fire/smoke rated barrier walls.

Findings Include:

At 1:55 PM on October 23, 2014 it is observed through inspection that there is a missing section of wall in the one hour rated fire/smoke barrier wall located above the ceiling, in the corridor, on the fourth floor near the door to the inpatient rehab gym, room number BT466.

Based upon observations the there are penetrations in the fire rated ceiling that is not fire stopped to maintain the required fire resistance rating of the ceiling and there is fire proofing of the structural steel is missing.

Findings include

On 10/21/14 around 1:48 PM it is observed that the sprinkler hangers and pipe penetrates the fire rated ceiling and is not fire stopped with a listed design and product in the equipment storage room on the first floor.

On 10/21/14 around 4:06 PM it is observed that fire proofing of the structural steel is not installed at hanger connections on the south side of the second floor.

Based upon observations of all corridor doors there are doors found that did not have positive latching that could allow smoke to pass through the doors.

Findings include

On 10/21/14 around 2:10 PM it is observed that the door coordinator to the corridor door to radiation room 1 is not working properly and not allowing the doors to be self closing and latching.

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 10/21/14 around 3:25 PM it is observed that there is an opening in smoke barrier wall above the door to impinging wing on first floor that is not fire stopped with a listed design and product.

On 10/21/14 around 4:06 PM it is observed that there are openings in smoke barrier wall in ultrasound that is not fire stopped with a listed design and product on the second floor.

On 10/21/14 around 5:00 PM it is observed that there is a penetration in the smoke barrier wall above the back door of woman's imaging that is not fire stopped with a listed design and product.

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 10/24/14 around 10:16 AM it is observed that the center fire rated smoke barrier wall above the cross corridor doors has penetrations of mc cable that are not fire stopped with a listed design and product on the 6th floor in the medical office building.


On 10/24/14 around 10:20 AM it is observed that there was an opening in the smoke barrier wall west and north of the center smoke barrier door on the sixth floor and there are penetrations in the smoke barrier wall that are not fire stopped or repaired with a listed design and product in suite 605 on the 6th floor in the medical office building.

During review of the drawings on show the northeast and northwest wall are a fire rated smoke barrier wall and the door, frame and glass panels are not listed as fire rated assemblies near the elevator lobby on the 6th floor of the medical office building.

On 10/24/14 between 11: 56 AM and 12:24 AM it is observed that there are penetrations in the smoke barrier wall in treatment room 1 in suite 304 that is not fire stopped with a listed design and product on the 3rd floor in the medical office building.

Based upon observations the fire rated smoke barrier walls have penetrations, joints at top of wall, or 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 10/24/14 around 11:10 AM it is observed that there are penetrations in center fire rated smoke barrier wall above the door where mc cable and low voltage sleeve that are not fire stopped with a listed design and product on the 5th floor in the medical office building.

Based upon observations the smoke barrier fire rated doors are not fully closing and could allow smoke to pass through the doors.

Findings include

On 10/21/14 around 2:02 PM it is observed that the smoke barrier door by radiation 2 is not fully closing.

On 10/21/14 around 5:01 PM it is observed that rear smoke barrier door is not self closing in suite 230.

Based upon observations the smoke barrier fire rated doors have gaps between the door and the astragal and doors are not self closing and could allow smoke to pass through the doors.

Findings include

On 10/24/14 around 9:37 AM it is observed that the smoke barrier door is not self closing and latching on the sixth floor by elevator in the medical office building.

On 10/24/14 between 10:58 AM and 11:00 AM it is observed that the door to suite 606 in the smoke barrier wall of the corridor is not labeled and listed fire door on the 6th floor in the medical office building.

On 10/24/14 between 11:25 AM and 11:56 AM it is observed that fire rated smoke barrier door to rehabilitation room 438 has a gap that is greater than 1/8 inch on the 4th floor in the medical office building.

On 10/24/14 around 1:56 PM it is observed that there is a smoke barrier door at the atrium that the air force keeps prevents the door from fully closing on the 2nd floor in the medical office building.

On 10/24/14 around 3:00 PM it is observed that there is smoke barrier door that is held open with a non approved hold open device to the office of the Assistant CEO on the 1st floor in the medical office building.

Based upon observations there are locations in the facility where there are no exit signs to direct occupants to the exits.

Findings include

On 10/24/14 between 11:52 AM and 12:25 PM it is observed that that there are no exit signs directing occupants to the exits two means of exits at atrium on fourth and third floor.



30721

It is observed that the facility failed to continuously maintain Illuminated exit directional signs.

Findings Include:

At 3:48 PM on October 23, 2014 it is observed through inspection that an illuminated exit sign located in lab 101, on the first floor is nonoperational.

Based upon observations of the the fire alarm system that there are areas where the visual notification devices that are installed according to NFPA 72.

Findings include

On 10/21/14 around 4:15 PM it is observed that there is a visual fire alarm device that is above the ceiling in procedure room on the south side of the second.

During review of documentation of the fire alarm inspection reports it is noted that the reports show that all of the fire alarm initiation devices were not tested.

Findings include:

On 10/17/14 during review of the fire alarm inspection reports between 12:00 PM and 3:30 PM for the testing and inspection of the fire alarm system, the documentation dated 6/16/14 through 7/1/14 conducted by Siemens that there were smoke and beam detectors that were not test for functionality. The locations of the are as follows: rooms 521, 522,425,335, 330, 323, and the atrium beam detectors.

Based upon observations of the sprinkler system that there where the sprinklers are not parallel with the ceiling and the piping is not supported from the structure.

Findings include

On 10/21/14 around 1:48 PM it is observed that the sprinkler heads are not parallel with the ceiling in the equipment storage room on the first floor.

On 10/21/14 around 1:50 PM it is observed that the sprinkler pipe is supported by sheet rock and not the structure.

On 10/21/14 between 1:55 PM and 2:02 PM it is observed that the sprinkler heads are not parallel with the ceiling in the Medication room.

Based on observations, the means of egress is not being continuously maintained free of obstructions or impediments.

Findings Include:

At 2:03 PM on October 23, 2014 it is observed that there is 3 beds in the corridor located near room 410 on the fourth floor. These items obstruct the path of egress travel and diminishes the path of egress travel corridor width.

At 2:22 PM on October 23, 2014 it is observed that the path of egress travel leading to the MIU is obstructed by chairs and desks located near room 316.
It is noted that the current wall configuration differs from the approved building construction plans provided by the facility.

Based upon observations that the requirements for the HVAC systems and electrical systems are not being maintained.

Findings Include

On 10/24/14 around 11:00 AM it is observed that there is an electrical room and there is no sign designating that the room is an electrical room on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 11:00 AM it is observed that there are screws missing to the cover of panel R in the electrical room on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 between 11:10 AM and 11:15 AM it is observed that there are combustible materials located above the return air plenum ceiling in suite 510 on the 5th floor in the medical office building. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/24/14 around 11:15 AM it is observed that there is a junction box for battery powered emergency lighting is supported by ceiling tile only and not supported to the structure in suite 510 on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 11:25 AM it is observed that there is a junction box that has fire alarm cable that not connected in suite 510 on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting and observations that the requirements for egress is not being maintained and exit lights are not directing occupants to the exits.

Findings include

During review of documentation on 10/22/14 around 11:25 AM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours in suite 117. Referenced Section 7.9.3

On 10/22/14 between 11:25 AM and 12:30 PM it is observed that there is a double keyed dead bolt lock on the exit door in the staff lounge and does not have a sign on the door that has contrasting durable letters not less than one inch high on contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED
WHEN THE BUILDING IS OCCUPIED
Referenced Sections 38.2.2.2.2, exception 2 of 7.2.1.5.1

On 10/22/14 between 11:25 AM and 12:30 PM it is observed that are areas in the corridor that there are no exit signs that direct occupants to the exits. Referenced Sections 38.2.10, 7.10

On 10/22/14 between 11:25 AM and 12:30 PM it is observed that there is storage shelving in the back corridor that obstructs the clear width of egress. Referenced Sections 38.2.1.1, 7.1.10.2.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting and observations that the requirements for egress is not being maintained, the electrical systems are not being maintained, the construction of the fire rated walls that separate the mixed occupancies are not being maintained and exit lights are not directing occupants to the exits.

Findings include

On 10/22/14 around 2:00 PM it is observed that there the clear working space in front of electrical panels A and B is not being maintained clear in the electrical room. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 2:00 PM it is observed that for panel A in the electrical that there is no panel schedule noting what circuit or equipment that each breaker supplies. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 2:10 it is observed that there are parking blocks installed in front of the rear exit doors that create a tripping hazard. Referenced Sections 38.2.1.1, 71.10.2.2

On 10/22/14 around 2:25 PM it is observed that there are areas in the waiting room that do not have exit signs to direct occupants to the exits. Referenced Sections 38.2.10, 7.10

During review of documentation on 10/22/14 around 1:00 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 2:50 PM it is observed that the west fire rated wall does not continue to the front sheathing between the two mixed occupancies. Referenced Sections 38.1.2.1, 6.1.14

On 10/22/ between 2:50 PM and 3:10 PM it is observed that the east fire rated wall does not continue to the front exterior sheating, has penetrations in the wall that are not fire stopped with a listed design and product, that there is a steel beam that is part of the wall and is not protected with construction to provide the 2-hour fire resistant rating between the two mixed occupancies. Referenced Sections 38.1.2.1, 6.1.14

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, and observations that the requirements for the HVAC systems, electrical systems, egress, are not being maintained.

Findings include

On 10/22/14 around 8:18 AM it is observed that there is a non approved multi plug adapter at the television in waiting room of suite 117. Referenced Sections 38.5.1, 9.1.2

During review of documentation on 10/22/14 around 8:27 AM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours in suite 117. Referenced Section 7.9.3


On 10/22/14 around 8:40 AM it is observed that there is cover missing to VAV HVAC unit above the ceiling in the corridor outside of room 24 of suite 117. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 8:40 AM it is observed that there is combustible is a wood blocking above the ceiling and the ceiling is a return air plenum in room 23 of suite 117. Referenced Sections 38.5.2, 9.2

On 10/22/14 around 8:47 AM it is observed that top storage is located above the clear distance of 18 inches below the sprinkler head deflector in the storage room by south rear exit of suite 117. Referenced Sections 38.1.5.2 NFPA 13

On 10/22/14 around 8:54 AM it is observed that there is printer stand that obstructs the clear egress width egress at nurse ' s station west side of suite 117. Referenced Sections 38.2.1.1, 7.1.10.2.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, and observations that the requirements of the electrical systems and sprinkler systems are not being maintained.

Findings include

During review of documentation on 10/22/14 around 8:27 AM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours in suite 117. Referenced Section 7.9.3 .

On 10/22/14 around 9:08 AM it is observed that there is a junction box that is not secured to the structure and there is a cover to VAV HVAC unit that is not completely attached to the box of suite 209. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 9:12 AM it is observed that there is a sprinkler head that is closer than 4 inches from the wall and would affect the operation of the sprinkler system.

On 10/22/14 around 9:20 AM it is observed that there is an opening in the main switch gear in main electrical room that is not closed. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 9:22 AM it is observed that electrical panel directory for panel H1A is not complete and there is a panel next to A that is not labeled as panel number or letters in the main electrical room. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 9:26 AM it is observed that Time clock is not secured to the structure in main electrical room screws are missing for cover to panel A in the main electrical room. Referenced Sections 38.5.1, 9.1.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, and the emergency evacuation plan is not complete,and observations that the requirements for the fire alarm system, sprinkler systems, electrical systems, hazardous locations, means of egress are not being maintained in the medical office building.

Findings include


During review of documentation on 10/24/14 around 1:00 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 9:38 AM it is observed that there is damaged fire proofing and hangers connection are not fire proofed of the structural steel and that is a electrical Junction box that is in the fire proofing on the 6th floor in the room behind the elevators in the medical office building. Referenced Sections 38.1.2.1, 6.1.14

On 10/24/14 around 9:42 AM it is observed that the fire rated elevator machine room door is not self closing and latching in the medical office building. Referenced Sections 38.5.3

On 10/24/14 around 9:43 AM it is observed that the elevator machine door has a gap of one inch between the bottom of the door and the finished floor that is greater than allowed as referenced by NFPA 80 in the medical office building. Referenced Sections 38.5.3

During review of the emergency evacuation plans on 10/24/14 between 10:00 AM and 12:00 PM and it is noted that the plans are not specifically detailed according to the locations in the medical office building. Referenced Section 38.7

On 10/24/14 around 10:05 AM it is observed that the clear working space in front of HVAC control panels is not being maintained clear of storage and furniture on the 6th floor in the HVAC control room in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 10:10 AM it is observed that there is a sprinkler control valve located above the ceiling south side of smoke at elevator lobby that do not have a sign noting that there is a sprinkler control valve above the ceiling on the 6th floor in the medical office building. Referenced Sections 38.1.5.2 NFPA 13

On 10/24/14 between 10:16 AM and 10:20 AM it is observed that there is electrical cable that is not supported above the ceiling according to NFPA 70 National Electrical Code at the center smoke barrier doors and in suite 605 on the 6th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 10:20 AM it is observed that there are remote duct detector test switches and the outlet box is only attached to the ceiling tile and not to the structure in suite 605 on the 6th floor in the medical office building. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/24/14 around 10:33 AM it is observed that there is ceiling tile missing in suite 601 north of the smoke barrier wall that could allow hot gases the pas above the ceiling and affect the operation of the sprinkler system. Referenced Sections 38.1.5.2 NFPA 13

On 10/24/14 around 10:35 AM it is observed that there is a smoke detector that is too close to a supply air diffuser in Suite 601 by the sink on the 6th floor in the medical office building. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/24/14 around 10:54 AM it is observed that electrical junction box cover is missing in exam room 7 in suite 600 on the 6th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 11:56 AM it is observed that the smoke partition door is held open with a non approved hold open device and is not self closing and latching to supply room 445 on the 4th floor in the medical office building. Referenced Sections 38.2.2.1, 8.4

On 10/24/14 around 12:24 PM it is observed that there is an electrical room and there is no sign designating that the room is an electrical room on the 3rd floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 12:24 PM it is observed that there is an electrical panel that is not labeled and there is no panel directory designating what circuit or equipment that the breakers supply in the electrical room on the 3rd floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 2:15 PM it is observed that there soiled utility room the door that is not self closing and latching at west center smoke barrier door 2:15 on the 2nd floor in the medical office building. Referenced Sections 38.2.2.1, 8.4

On 10/24/14 around 2:25 PM it is observed that there is a storage room that is part of the means of egress from the corridor by control desk on the 2nd floor in the medical office building. Referenced Sections 38.2.1.1, 71.10.2.2

On 10/24/14 between 2:25 PM and 3:00 AM it is observed that there is a conference room in admin area and there is no visual fire alarm device on the 1st floor in the medical office building. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/24/14 around 3:15 PM it is observed that supporting of the of low voltage cable and mc cable is not supported according to NFPA 70 National Electric Code in the corridor on the first floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 3:30 PM it is observed that there are penetrations of electrical conduit and boiler flue of the fire rated walls of the boiler room that are not fire stopped with a listed design and product on the first floor in the medical office building. Referenced Sections 38.1.2.1, 6.1.14

On 10/24/14 around 3:30 PM it is observed that there are penetrations of the fire rated walls of the fire pump room that are not fire stopped with a listed design and product on the first floor in the medical office building. Referenced Sections 38.1.2.1, 6.1.14

On 10/24/14 around 3:30 PM it is observed that there are breakers on the emergency generator that are not labeled as to the circuits or equipment that the serve and the location of where the circuits or equipment are located. There is a fire pump controller that is not labeled as to what and where the locations are of the breakers that feed the controller in the medical office building. Referenced Sections 38.5.1, 9.1.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, emergency generator and the emergency evacuation plan is not complete, and observations that the requirements for the fire alarm systems and HVAC systems are not being maintained.

Findings include

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that evacuation plans does not show fire extinguishers, pull stations, and evacuation routes on the drawing that is part of the emergency evacuation plan. 2009 Virginia Statewide Fire Prevention Code Section 404.3.2

During review of documentation on 10/20/14 that there is no documentation at time of survey noting that the emergency generator has been inspected weekly. Referenced Section 7.9.2.3

During review of documentation on 10/20/14 around 12:40 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Section 7.9.3

On 10/20/14 between 3:26 PM and 3:43 PM it is observed that there is oxygen stored in the supply room by nurse station and on the south side in Suite 250 and there are no " No Smoking " signs on or near the door. Referenced by Virginia Statewide Fire Prevention Code Section 4006.6.1

On 10/20/14 around 3:30 PM it is observed that there is a smoke detector that is too close to the wall in suite 250 janitor supply closet. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/20/14 around 3:50 PM it is observed that there are combustible plastic caps that are lying on the ceiling and the ceiling is a return air plenum on the south side of suite 250. Referenced Sections 38.3.4.2, 9.6.2.1

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, emergency generator and the emergency evacuation plan is not complete, there are items noted in the sprinkler inspection report that have not been corrected and observations that the requirements for the fire alarm system, sprinkler systems are not being maintained.

Findings include

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that the sprinkler report dated 9/24/14 noted that there are caulked concealed sprinkler escutcheons in the first floor woman's bath, first floor hallway at suite 170 at rear exit door, that the required quantity and type of sprinkler heads are not in the sprinkler storage cabinet and the wrench is missing. Referenced Sections 38.1.5.2 NFPA 13

On 10/20/14 around 1:00 PM it is observed that there are openings in the ceiling where the column and rain leader penetrates the ceiling that could allow hot gases to pass above the ceiling and affect the operation of the sprinkler system on the third floor. Referenced Sections 38.1.5.2 NFPA 13

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that the sprinkler report dated 9/24/14 noted that in physical therapy and sports suite 300 that there are painted sprinkler heads near free weight station, a damaged sprinkler head near mini trampoline and 3rd floor data closet Referenced Sections 38.1.5.2 NFPA 13

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that evacuation plans does not show fire extinguishers, pull stations, and evacuation routes on the drawing that is part of the emergency evacuation plan. 2009 Virginia Statewide Fire Prevention Code Section 404.3.2

During review of documentation on 10/20/14 that there is no documentation at time of survey noting that the emergency generator has been inspected weekly. Referenced Section 7.9.2.3

During review of documentation on 10/20/14 around 12:40 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Section 7.9.3

On 10/20/14 around 2:20 PM it is observed that there the fire rated stairway door is not self closing and latching on the third floor of stair 2. Referenced Section 7.2.1.8.1

On 10/20/14 between 2:30 PM and 3:00 PM it is observed that there are smoke detectors that are too close to supply air diffusers in suite 300 in Modality and in the front office. Referenced Section 38.3.4.1, 9.6

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, emergency generator and the emergency evacuation plan is not complete, there are items noted in the sprinkler inspection report that have not been corrected and observations that the requirements for the sprinkler systems and elevators are not being maintained.

Findings include

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that the sprinkler report dated 9/24/14 noted that there are caulked concealed sprinkler escutcheons in the first floor woman's bath, first floor hallway at suite 170 at rear exit door, that the required quantity and type of sprinkler heads are not in the sprinkler storage cabinet and the wrench is missing. Referenced Sections 38.1.5.2 NFPA 13

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that evacuation plans does not show fire extinguishers, pull stations, and evacuation routes on the drawing that is part of the emergency evacuation plan. 2009 Virginia Statewide Fire Prevention Code Section 404.3.2

During review of documentation on 10/20/14 that there is no documentation at time of survey noting that the emergency generator has been inspected weekly. Referenced Section 7.9.2.3

During review of documentation on 10/20/14 around 12:40 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Section 7.9.3

On 10/22/14 between 1:00 PM and 1:27 PM it is observed that there is a detached sprinkler pipe hanger in IT closet in suite 100. Referenced Sections 38.1.5.2 NFPA 13

On 10/20/14 around 3:56 PM it is observed that there is maintenance equipment that is stored in the elevator machine room. Only items associated with elevators are allowed in the machine room. Referenced Sections 38.5.3, 9.4

On 10/20/14 around 4:05 PM it is observed that there is an opening in the ceiling in the IT closet in Suite 150 that could allow hot gases to pass above the ceiling and affect the operation of the sprinkler system. Referenced Sections 38.1.5.2 NFPA 13

Based upon review of documentation there is documentation that is not available at the time of the survey for the inspection and testing of the fire pump, emergency generator, fire extinguisher training and evacuation procedure staff training.

Findings include

During review of documentation on 10/27/14 between 10:00 AM and 10:27 AM a question was asked of the manager if there were inspection and testing reports for the weekly test of the fire pump and the answer was they did not have the reports at the time of survey. Referenced Sections 12.3.5, 9.7

During review of documentation on 10/27/14 between 10:00 AM and 10:27 AM a question was asked of the manager if there were inspection and testing reports for the weekly inspection and monthly test under load for the emergency generator and the answer was they did not have the reports at the time of survey. Referenced Section 7.9.2.3

During review of documentation on 10/27/14 between 10:00 AM and 10:27 AM a question was asked of the manager if there was documentation that the staff has had annual training on the use of fire extinguishers and the answer was they did not have the reports at the time of survey. Referenced Section 12.7.6.2

During review of documentation on 10/27/14 between 10:00 AM and 10:27 AM a question was asked of the manager if there was documentation that the staff has had training on the evacuation procedures and the answer was they did not have the reports at the time of survey. Referenced Section 12.7.6.1

Based upon observations there are oxygen tanks stored in a room and there is no no smoking sign near the door.

Findings include

On 10/21/14 around 1:55 PM it is observed that there is oxygen stored in the equipment storage room and there is no " No Smoking " sign on or near the door.

Based upon review of documentation and interviews that there is not complete documentation of the testing and inspection of the emergency generator according NFPA 110.

Findings include

During review of documentation on 10/27/14 between 1:15 PM and 1:48 PM that there is no documentation noting that the weekly inspections of the emergency generator is being done. The monthly generator load is less than 30% and there is no documentation showing the emergency generator has been tested using a load bank annually.

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

Findings include

On 10/21/14 around 3:15 PM it is observed that there are circuits originating from the emergency life safety branch panel 1LLS that are not allowed to be fed from the life safety branch. The circuits are; low voltage tree lights, GFCI receptacle in med gas area and irrigation controls.

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

Findings include

On 10/21/14 around 3:02 PM it is observed that the electrical panels at generator are not labeled noting what circuits or equipment that the breaker supplies.

On 10/21/14 around 3:40 PM it is observed that there is an opening in electrical trough that is not closed in electrical room on the second floor.

On 10/21/14 around 3:40 PM it is observed that there is an opening in electrical panel 2DPEQ in the electrical room on the second floor that is not closed.

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

Findings include

On 10/24/14 around 9:22 AM it is observed that there is an opening in an electrical junction box that is not closed above the ceiling in inpatient rehabilitation on the fourth floor.

Based upon observations the fire rated walls that are not constructed to maintain the required fire resistance rating.

Findings include

On 10/24/14 around 9:05 AM it is observed that there is a fire rated wall that is not installed according the listed design at inpatient rehabilitation on the fourth floor.

On 10/24/14 around 9:15 AM it is observed that there is exposed combustible foam board at the north side behind the wall on near inpatient rehabilitation on the fourth floor.


30721

Based on observations the facility failed to properly maintain fire/smoke rated barrier walls.

Findings Include:

At 1:55 PM on October 23, 2014 it is observed through inspection that there is a missing section of wall in the one hour rated fire/smoke barrier wall located above the ceiling, in the corridor, on the fourth floor near the door to the inpatient rehab gym, room number BT466.

Based upon observations the there are penetrations in the fire rated ceiling that is not fire stopped to maintain the required fire resistance rating of the ceiling and there is fire proofing of the structural steel is missing.

Findings include

On 10/21/14 around 1:48 PM it is observed that the sprinkler hangers and pipe penetrates the fire rated ceiling and is not fire stopped with a listed design and product in the equipment storage room on the first floor.

On 10/21/14 around 4:06 PM it is observed that fire proofing of the structural steel is not installed at hanger connections on the south side of the second floor.

Based upon observations of all corridor doors there are doors found that did not have positive latching that could allow smoke to pass through the doors.

Findings include

On 10/21/14 around 2:10 PM it is observed that the door coordinator to the corridor door to radiation room 1 is not working properly and not allowing the doors to be self closing and latching.

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 10/21/14 around 3:25 PM it is observed that there is an opening in smoke barrier wall above the door to impinging wing on first floor that is not fire stopped with a listed design and product.

On 10/21/14 around 4:06 PM it is observed that there are openings in smoke barrier wall in ultrasound that is not fire stopped with a listed design and product on the second floor.

On 10/21/14 around 5:00 PM it is observed that there is a penetration in the smoke barrier wall above the back door of woman's imaging that is not fire stopped with a listed design and product.

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 10/24/14 around 10:16 AM it is observed that the center fire rated smoke barrier wall above the cross corridor doors has penetrations of mc cable that are not fire stopped with a listed design and product on the 6th floor in the medical office building.


On 10/24/14 around 10:20 AM it is observed that there was an opening in the smoke barrier wall west and north of the center smoke barrier door on the sixth floor and there are penetrations in the smoke barrier wall that are not fire stopped or repaired with a listed design and product in suite 605 on the 6th floor in the medical office building.

During review of the drawings on show the northeast and northwest wall are a fire rated smoke barrier wall and the door, frame and glass panels are not listed as fire rated assemblies near the elevator lobby on the 6th floor of the medical office building.

On 10/24/14 between 11: 56 AM and 12:24 AM it is observed that there are penetrations in the smoke barrier wall in treatment room 1 in suite 304 that is not fire stopped with a listed design and product on the 3rd floor in the medical office building.

Based upon observations the fire rated smoke barrier walls have penetrations, joints at top of wall, or 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 10/24/14 around 11:10 AM it is observed that there are penetrations in center fire rated smoke barrier wall above the door where mc cable and low voltage sleeve that are not fire stopped with a listed design and product on the 5th floor in the medical office building.

Based upon observations the smoke barrier fire rated doors are not fully closing and could allow smoke to pass through the doors.

Findings include

On 10/21/14 around 2:02 PM it is observed that the smoke barrier door by radiation 2 is not fully closing.

On 10/21/14 around 5:01 PM it is observed that rear smoke barrier door is not self closing in suite 230.

Based upon observations the smoke barrier fire rated doors have gaps between the door and the astragal and doors are not self closing and could allow smoke to pass through the doors.

Findings include

On 10/24/14 around 9:37 AM it is observed that the smoke barrier door is not self closing and latching on the sixth floor by elevator in the medical office building.

On 10/24/14 between 10:58 AM and 11:00 AM it is observed that the door to suite 606 in the smoke barrier wall of the corridor is not labeled and listed fire door on the 6th floor in the medical office building.

On 10/24/14 between 11:25 AM and 11:56 AM it is observed that fire rated smoke barrier door to rehabilitation room 438 has a gap that is greater than 1/8 inch on the 4th floor in the medical office building.

On 10/24/14 around 1:56 PM it is observed that there is a smoke barrier door at the atrium that the air force keeps prevents the door from fully closing on the 2nd floor in the medical office building.

On 10/24/14 around 3:00 PM it is observed that there is smoke barrier door that is held open with a non approved hold open device to the office of the Assistant CEO on the 1st floor in the medical office building.

Based upon observations there are locations in the facility where there are no exit signs to direct occupants to the exits.

Findings include

On 10/24/14 between 11:52 AM and 12:25 PM it is observed that that there are no exit signs directing occupants to the exits two means of exits at atrium on fourth and third floor.



30721

It is observed that the facility failed to continuously maintain Illuminated exit directional signs.

Findings Include:

At 3:48 PM on October 23, 2014 it is observed through inspection that an illuminated exit sign located in lab 101, on the first floor is nonoperational.

Based upon observations of the the fire alarm system that there are areas where the visual notification devices that are installed according to NFPA 72.

Findings include

On 10/21/14 around 4:15 PM it is observed that there is a visual fire alarm device that is above the ceiling in procedure room on the south side of the second.

During review of documentation of the fire alarm inspection reports it is noted that the reports show that all of the fire alarm initiation devices were not tested.

Findings include:

On 10/17/14 during review of the fire alarm inspection reports between 12:00 PM and 3:30 PM for the testing and inspection of the fire alarm system, the documentation dated 6/16/14 through 7/1/14 conducted by Siemens that there were smoke and beam detectors that were not test for functionality. The locations of the are as follows: rooms 521, 522,425,335, 330, 323, and the atrium beam detectors.

Based upon observations of the sprinkler system that there where the sprinklers are not parallel with the ceiling and the piping is not supported from the structure.

Findings include

On 10/21/14 around 1:48 PM it is observed that the sprinkler heads are not parallel with the ceiling in the equipment storage room on the first floor.

On 10/21/14 around 1:50 PM it is observed that the sprinkler pipe is supported by sheet rock and not the structure.

On 10/21/14 between 1:55 PM and 2:02 PM it is observed that the sprinkler heads are not parallel with the ceiling in the Medication room.

Based on observations, the means of egress is not being continuously maintained free of obstructions or impediments.

Findings Include:

At 2:03 PM on October 23, 2014 it is observed that there is 3 beds in the corridor located near room 410 on the fourth floor. These items obstruct the path of egress travel and diminishes the path of egress travel corridor width.

At 2:22 PM on October 23, 2014 it is observed that the path of egress travel leading to the MIU is obstructed by chairs and desks located near room 316.
It is noted that the current wall configuration differs from the approved building construction plans provided by the facility.

Based upon observations that the requirements for the HVAC systems and electrical systems are not being maintained.

Findings Include

On 10/24/14 around 11:00 AM it is observed that there is an electrical room and there is no sign designating that the room is an electrical room on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 11:00 AM it is observed that there are screws missing to the cover of panel R in the electrical room on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 between 11:10 AM and 11:15 AM it is observed that there are combustible materials located above the return air plenum ceiling in suite 510 on the 5th floor in the medical office building. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/24/14 around 11:15 AM it is observed that there is a junction box for battery powered emergency lighting is supported by ceiling tile only and not supported to the structure in suite 510 on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 11:25 AM it is observed that there is a junction box that has fire alarm cable that not connected in suite 510 on the 5th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting and observations that the requirements for egress is not being maintained and exit lights are not directing occupants to the exits.

Findings include

During review of documentation on 10/22/14 around 11:25 AM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours in suite 117. Referenced Section 7.9.3

On 10/22/14 between 11:25 AM and 12:30 PM it is observed that there is a double keyed dead bolt lock on the exit door in the staff lounge and does not have a sign on the door that has contrasting durable letters not less than one inch high on contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED
WHEN THE BUILDING IS OCCUPIED
Referenced Sections 38.2.2.2.2, exception 2 of 7.2.1.5.1

On 10/22/14 between 11:25 AM and 12:30 PM it is observed that are areas in the corridor that there are no exit signs that direct occupants to the exits. Referenced Sections 38.2.10, 7.10

On 10/22/14 between 11:25 AM and 12:30 PM it is observed that there is storage shelving in the back corridor that obstructs the clear width of egress. Referenced Sections 38.2.1.1, 7.1.10.2.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting and observations that the requirements for egress is not being maintained, the electrical systems are not being maintained, the construction of the fire rated walls that separate the mixed occupancies are not being maintained and exit lights are not directing occupants to the exits.

Findings include

On 10/22/14 around 2:00 PM it is observed that there the clear working space in front of electrical panels A and B is not being maintained clear in the electrical room. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 2:00 PM it is observed that for panel A in the electrical that there is no panel schedule noting what circuit or equipment that each breaker supplies. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 2:10 it is observed that there are parking blocks installed in front of the rear exit doors that create a tripping hazard. Referenced Sections 38.2.1.1, 71.10.2.2

On 10/22/14 around 2:25 PM it is observed that there are areas in the waiting room that do not have exit signs to direct occupants to the exits. Referenced Sections 38.2.10, 7.10

During review of documentation on 10/22/14 around 1:00 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 2:50 PM it is observed that the west fire rated wall does not continue to the front sheathing between the two mixed occupancies. Referenced Sections 38.1.2.1, 6.1.14

On 10/22/ between 2:50 PM and 3:10 PM it is observed that the east fire rated wall does not continue to the front exterior sheating, has penetrations in the wall that are not fire stopped with a listed design and product, that there is a steel beam that is part of the wall and is not protected with construction to provide the 2-hour fire resistant rating between the two mixed occupancies. Referenced Sections 38.1.2.1, 6.1.14

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, and observations that the requirements for the HVAC systems, electrical systems, egress, are not being maintained.

Findings include

On 10/22/14 around 8:18 AM it is observed that there is a non approved multi plug adapter at the television in waiting room of suite 117. Referenced Sections 38.5.1, 9.1.2

During review of documentation on 10/22/14 around 8:27 AM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours in suite 117. Referenced Section 7.9.3


On 10/22/14 around 8:40 AM it is observed that there is cover missing to VAV HVAC unit above the ceiling in the corridor outside of room 24 of suite 117. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 8:40 AM it is observed that there is combustible is a wood blocking above the ceiling and the ceiling is a return air plenum in room 23 of suite 117. Referenced Sections 38.5.2, 9.2

On 10/22/14 around 8:47 AM it is observed that top storage is located above the clear distance of 18 inches below the sprinkler head deflector in the storage room by south rear exit of suite 117. Referenced Sections 38.1.5.2 NFPA 13

On 10/22/14 around 8:54 AM it is observed that there is printer stand that obstructs the clear egress width egress at nurse ' s station west side of suite 117. Referenced Sections 38.2.1.1, 7.1.10.2.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, and observations that the requirements of the electrical systems and sprinkler systems are not being maintained.

Findings include

During review of documentation on 10/22/14 around 8:27 AM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours in suite 117. Referenced Section 7.9.3 .

On 10/22/14 around 9:08 AM it is observed that there is a junction box that is not secured to the structure and there is a cover to VAV HVAC unit that is not completely attached to the box of suite 209. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 9:12 AM it is observed that there is a sprinkler head that is closer than 4 inches from the wall and would affect the operation of the sprinkler system.

On 10/22/14 around 9:20 AM it is observed that there is an opening in the main switch gear in main electrical room that is not closed. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 9:22 AM it is observed that electrical panel directory for panel H1A is not complete and there is a panel next to A that is not labeled as panel number or letters in the main electrical room. Referenced Sections 38.5.1, 9.1.2

On 10/22/14 around 9:26 AM it is observed that Time clock is not secured to the structure in main electrical room screws are missing for cover to panel A in the main electrical room. Referenced Sections 38.5.1, 9.1.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, and the emergency evacuation plan is not complete,and observations that the requirements for the fire alarm system, sprinkler systems, electrical systems, hazardous locations, means of egress are not being maintained in the medical office building.

Findings include


During review of documentation on 10/24/14 around 1:00 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 9:38 AM it is observed that there is damaged fire proofing and hangers connection are not fire proofed of the structural steel and that is a electrical Junction box that is in the fire proofing on the 6th floor in the room behind the elevators in the medical office building. Referenced Sections 38.1.2.1, 6.1.14

On 10/24/14 around 9:42 AM it is observed that the fire rated elevator machine room door is not self closing and latching in the medical office building. Referenced Sections 38.5.3

On 10/24/14 around 9:43 AM it is observed that the elevator machine door has a gap of one inch between the bottom of the door and the finished floor that is greater than allowed as referenced by NFPA 80 in the medical office building. Referenced Sections 38.5.3

During review of the emergency evacuation plans on 10/24/14 between 10:00 AM and 12:00 PM and it is noted that the plans are not specifically detailed according to the locations in the medical office building. Referenced Section 38.7

On 10/24/14 around 10:05 AM it is observed that the clear working space in front of HVAC control panels is not being maintained clear of storage and furniture on the 6th floor in the HVAC control room in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 10:10 AM it is observed that there is a sprinkler control valve located above the ceiling south side of smoke at elevator lobby that do not have a sign noting that there is a sprinkler control valve above the ceiling on the 6th floor in the medical office building. Referenced Sections 38.1.5.2 NFPA 13

On 10/24/14 between 10:16 AM and 10:20 AM it is observed that there is electrical cable that is not supported above the ceiling according to NFPA 70 National Electrical Code at the center smoke barrier doors and in suite 605 on the 6th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 10:20 AM it is observed that there are remote duct detector test switches and the outlet box is only attached to the ceiling tile and not to the structure in suite 605 on the 6th floor in the medical office building. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/24/14 around 10:33 AM it is observed that there is ceiling tile missing in suite 601 north of the smoke barrier wall that could allow hot gases the pas above the ceiling and affect the operation of the sprinkler system. Referenced Sections 38.1.5.2 NFPA 13

On 10/24/14 around 10:35 AM it is observed that there is a smoke detector that is too close to a supply air diffuser in Suite 601 by the sink on the 6th floor in the medical office building. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/24/14 around 10:54 AM it is observed that electrical junction box cover is missing in exam room 7 in suite 600 on the 6th floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 11:56 AM it is observed that the smoke partition door is held open with a non approved hold open device and is not self closing and latching to supply room 445 on the 4th floor in the medical office building. Referenced Sections 38.2.2.1, 8.4

On 10/24/14 around 12:24 PM it is observed that there is an electrical room and there is no sign designating that the room is an electrical room on the 3rd floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 12:24 PM it is observed that there is an electrical panel that is not labeled and there is no panel directory designating what circuit or equipment that the breakers supply in the electrical room on the 3rd floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 2:15 PM it is observed that there soiled utility room the door that is not self closing and latching at west center smoke barrier door 2:15 on the 2nd floor in the medical office building. Referenced Sections 38.2.2.1, 8.4

On 10/24/14 around 2:25 PM it is observed that there is a storage room that is part of the means of egress from the corridor by control desk on the 2nd floor in the medical office building. Referenced Sections 38.2.1.1, 71.10.2.2

On 10/24/14 between 2:25 PM and 3:00 AM it is observed that there is a conference room in admin area and there is no visual fire alarm device on the 1st floor in the medical office building. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/24/14 around 3:15 PM it is observed that supporting of the of low voltage cable and mc cable is not supported according to NFPA 70 National Electric Code in the corridor on the first floor in the medical office building. Referenced Sections 38.5.1, 9.1.2

On 10/24/14 around 3:30 PM it is observed that there are penetrations of electrical conduit and boiler flue of the fire rated walls of the boiler room that are not fire stopped with a listed design and product on the first floor in the medical office building. Referenced Sections 38.1.2.1, 6.1.14

On 10/24/14 around 3:30 PM it is observed that there are penetrations of the fire rated walls of the fire pump room that are not fire stopped with a listed design and product on the first floor in the medical office building. Referenced Sections 38.1.2.1, 6.1.14

On 10/24/14 around 3:30 PM it is observed that there are breakers on the emergency generator that are not labeled as to the circuits or equipment that the serve and the location of where the circuits or equipment are located. There is a fire pump controller that is not labeled as to what and where the locations are of the breakers that feed the controller in the medical office building. Referenced Sections 38.5.1, 9.1.2

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, emergency generator and the emergency evacuation plan is not complete, and observations that the requirements for the fire alarm systems and HVAC systems are not being maintained.

Findings include

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that evacuation plans does not show fire extinguishers, pull stations, and evacuation routes on the drawing that is part of the emergency evacuation plan. 2009 Virginia Statewide Fire Prevention Code Section 404.3.2

During review of documentation on 10/20/14 that there is no documentation at time of survey noting that the emergency generator has been inspected weekly. Referenced Section 7.9.2.3

During review of documentation on 10/20/14 around 12:40 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Section 7.9.3

On 10/20/14 between 3:26 PM and 3:43 PM it is observed that there is oxygen stored in the supply room by nurse station and on the south side in Suite 250 and there are no " No Smoking " signs on or near the door. Referenced by Virginia Statewide Fire Prevention Code Section 4006.6.1

On 10/20/14 around 3:30 PM it is observed that there is a smoke detector that is too close to the wall in suite 250 janitor supply closet. Referenced Sections 38.3.4.2, 9.6.2.1

On 10/20/14 around 3:50 PM it is observed that there are combustible plastic caps that are lying on the ceiling and the ceiling is a return air plenum on the south side of suite 250. Referenced Sections 38.3.4.2, 9.6.2.1

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, emergency generator and the emergency evacuation plan is not complete, there are items noted in the sprinkler inspection report that have not been corrected and observations that the requirements for the fire alarm system, sprinkler systems are not being maintained.

Findings include

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that the sprinkler report dated 9/24/14 noted that there are caulked concealed sprinkler escutcheons in the first floor woman's bath, first floor hallway at suite 170 at rear exit door, that the required quantity and type of sprinkler heads are not in the sprinkler storage cabinet and the wrench is missing. Referenced Sections 38.1.5.2 NFPA 13

On 10/20/14 around 1:00 PM it is observed that there are openings in the ceiling where the column and rain leader penetrates the ceiling that could allow hot gases to pass above the ceiling and affect the operation of the sprinkler system on the third floor. Referenced Sections 38.1.5.2 NFPA 13

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that the sprinkler report dated 9/24/14 noted that in physical therapy and sports suite 300 that there are painted sprinkler heads near free weight station, a damaged sprinkler head near mini trampoline and 3rd floor data closet Referenced Sections 38.1.5.2 NFPA 13

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that evacuation plans does not show fire extinguishers, pull stations, and evacuation routes on the drawing that is part of the emergency evacuation plan. 2009 Virginia Statewide Fire Prevention Code Section 404.3.2

During review of documentation on 10/20/14 that there is no documentation at time of survey noting that the emergency generator has been inspected weekly. Referenced Section 7.9.2.3

During review of documentation on 10/20/14 around 12:40 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Section 7.9.3

On 10/20/14 around 2:20 PM it is observed that there the fire rated stairway door is not self closing and latching on the third floor of stair 2. Referenced Section 7.2.1.8.1

On 10/20/14 between 2:30 PM and 3:00 PM it is observed that there are smoke detectors that are too close to supply air diffusers in suite 300 in Modality and in the front office. Referenced Section 38.3.4.1, 9.6

Based upon review of documentation that there is documentation that is not available at the time of the survey for the inspection and testing of the emergency lighting, emergency generator and the emergency evacuation plan is not complete, there are items noted in the sprinkler inspection report that have not been corrected and observations that the requirements for the sprinkler systems and elevators are not being maintained.

Findings include

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that the sprinkler report dated 9/24/14 noted that there are caulked concealed sprinkler escutcheons in the first floor woman's bath, first floor hallway at suite 170 at rear exit door, that the required quantity and type of sprinkler heads are not in the sprinkler storage cabinet and the wrench is missing. Referenced Sections 38.1.5.2 NFPA 13

During review of documentation on 10/20/14 between 11:30 PM and 12:30 PM that evacuation plans does not show fire extinguishers, pull stations, and evacuation routes on the drawing that is part of the emergency evacuation plan. 2009 Virginia Statewide Fire Prevention Code Section 404.3.2

During review of documentation on 10/20/14 that there is no documentation at time of survey noting that the emergency generator has been inspected weekly. Referenced Section 7.9.2.3

During review of documentation on 10/20/14 around 12:40 PM that there is no documentation at time of survey that the battery powered emergency lights have been tested and inspected monthly for 30 seconds and annually for 1 ½ hours. Referenced Section 7.9.3

On 10/22/14 between 1:00 PM and 1:27 PM it is observed that there is a detached sprinkler pipe hanger in IT closet in suite 100. Referenced Sections 38.1.5.2 NFPA 13

On 10/20/14 around 3:56 PM it is observed that there is maintenance equipment that is stored in the elevator machine room. Only items associated with elevators are allowed in the machine room. Referenced Sections 38.5.3, 9.4

On 10/20/14 around 4:05 PM it is observed that there is an opening in the ceiling in the IT closet in Suite 150 that could allow hot gases to pass above the ceiling and affect the operation of the sprinkler system. Referenced Sections 38.1.5.2 NFPA 13

Based upon review of documentation there is documentation that is not available at the time of the survey for the inspection and testing of the fire pump, emergency generator, fire extinguisher training and evacuation procedure staff training.

Findings include

During review of documentation on 10/27/14 between 10:00 AM and 10:27 AM a question was asked of the manager if there were inspection and testing reports for the weekly test of the fire pump and the answer was they did not have the reports at the time of survey. Referenced Sections 12.3.5, 9.7

During review of documentation on 10/27/14 between 10:00 AM and 10:27 AM a question was asked of the manager if there were inspection and testing reports for the weekly inspection and monthly test under load for the emergency generator and the answer was they did not have the reports at the time of survey. Referenced Section 7.9.2.3

During review of documentation on 10/27/14 between 10:00 AM and 10:27 AM a question was asked of the manager if there was documentation that the staff has had annual training on the use of fire extinguishers and the answer was they did not have the reports at the time of survey. Referenced Section 12.7.6.2

During review of documentation on 10/27/14 between 10:00 AM and 10:27 AM a question was asked of the manager if there was documentation that the staff has had training on the evacuation procedures and the answer was they did not have the reports at the time of survey. Referenced Section 12.7.6.1

Based upon observations there are oxygen tanks stored in a room and there is no no smoking sign near the door.

Findings include

On 10/21/14 around 1:55 PM it is observed that there is oxygen stored in the equipment storage room and there is no " No Smoking " sign on or near the door.

Based upon review of documentation and interviews that there is not complete documentation of the testing and inspection of the emergency generator according NFPA 110.

Findings include

During review of documentation on 10/27/14 between 1:15 PM and 1:48 PM that there is no documentation noting that the weekly inspections of the emergency generator is being done. The monthly generator load is less than 30% and there is no documentation showing the emergency generator has been tested using a load bank annually.

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

Findings include

On 10/21/14 around 3:15 PM it is observed that there are circuits originating from the emergency life safety branch panel 1LLS that are not allowed to be fed from the life safety branch. The circuits are; low voltage tree lights, GFCI receptacle in med gas area and irrigation controls.

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

Findings include

On 10/21/14 around 3:02 PM it is observed that the electrical panels at generator are not labeled noting what circuits or equipment that the breaker supplies.

On 10/21/14 around 3:40 PM it is observed that there is an opening in electrical trough that is not closed in electrical room on the second floor.

On 10/21/14 around 3:40 PM it is observed that there is an opening in electrical panel 2DPEQ in the electrical room on the second floor that is not closed.

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

Findings include

On 10/24/14 around 9:22 AM it is observed that there is an opening in an electrical junction box that is not closed above the ceiling in inpatient rehabilitation on the fourth floor.