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5.2.4 Swinging Doors with Builders Hardware of Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of the door assembly.
5.2.4.2 As a minimum, the following items shall be verified.
(1) No open holes or breaks exist in the surface of the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self closing device is operational: that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on observations and interview, it was determined the facility failed to ensure two 90-minute fire door assemblies could automatically close to a latched position.

Findings include:

Observations during tour on 09/28/22 between 8:30 a.m. and 10:30 a.m. with Staff A (Senior Director of Operations) and Staff B (Executive Assistant) revealed two 90-minute fire rated door assemblies that failed to automatically close to a full latched position when released from the magnetic hold-open device.
The fire door assemblies locations and conditions are as follows:
1. The 90-minute fire rated double door assembly, located inside the Main Hospital entrance, labeled # C 001, failed to fully close. The left hand door panel strikes the meeting edge of the right door panel, preventing a full closure.
2. The 90-minute fire rated double door assembly, located in the corridor outside the Emergency Department, labeled # C 008, failed to fully latch. The left hand door panel top latch was stuck in the retracted position failed to engage when the door panel was fully closed.

Interview on 09/28/22 with Staff A and Staff B confirmed the above findings, locations, and existing conditions.

Based on observations and interview, it was determined the facility failed to ensure the Paint Shop entrance door was equipped with an automatic door closing device and latching hardware, additionally, the side wall of the room is equipped with a metal access door hatch approximately 24" x 24", that fails to have hardware to secure the door in the fully closed position.

Findings include:

Observations during tour on 09/27/22 between 2:30 p.m. and 3:00 p.m. with Staff A (Senior Director of Operations) and Staff B (Executive Assistant) revealed the facilities Paint Shop, located on the ground level of the Bigelow unit, failed to have a rated door assembly with an automatic door closing device, and latching handle.
The working and storage space is in excess of 200 sq. ft.

Interview on 09/28/22 with Staff A and Staff B confirmed the above findings, location, and existing conditions.

NFPA 10 Standard for Portable Fire Extinguishers (2010 edition)

7.1.1 Responsibility. The owner or designated agent or occupant of a property in which fire extinguishers are located shall be responsible for inspection, maintenance, and recharging.
7.1.2.3 Persons performing 30-day inspections shall not be required to be certified.
7.2.1.2 Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device / system at a minimum of 30-day intervals.

Based on observations and interview, it was determined the facility failed to ensure that three fire extinguisher's were inspected on 30-day intervals.

Findings include:

Observations during tour on 09/27/22 and 09/28/22 with Staff A (Senior Director of Operations) and Staff B (Executive Assistant) revealed three fire extinguishers failed to be inspected every 30-days.
The fire extinguisher locations and missed monthly inspections are as follows:
1. The ABC fire extinguisher, located on the ground level of the Bigelow unit, failed to be inspected monthly since the annual vendor service/inspection was conducted on December 13th, 2021.
2. The ABC fire extinguisher, located inside the Physical Therapy department, failed to be inspected for January and February 2022. The fire extinguisher was inspected from March 2022 to the present.
3. The K-class fire extinguisher, located inside the main Kitchen, was last inspected on august 1st, 2022 (approximately 57 days).

Interview on 09/27/22 and 09/28/22 with Staff A and Staff B confirmed the above findings, locations, and monthly inspection tags.

NFPA 101 Life Safety Code (2012 edition)
8.5 Smoke Barriers
8.5.2.1 Smoke barriers required by this code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof.
8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Based on observations and interview, it was determined the facility failed to ensure smoke/fire barriers are maintained to resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 09/28/22 between 8:30 a.m. and 11:30 a.m. with Staff A (Senior Director of Operations) and Staff B (Executive Assistant) revealed four locations with unprotected penetrations through the barrier walls.
These locations and conditions are as follows:
1. There are six unprotected FMC (Flexible Metal Conduits) passing through the 1-hour fire barrier wall in the rear electrical room, next to the ambulance entrance.
2. There are two unprotected penetrations (copper water pipes) passing through the 1-hour fire barrier wall in electrical room # 1333.
3. There is one unprotected penetration (2" plastic conduit) passing through the smoke barrier wall, above the suspended ceiling, directly above the PACU (Post Acute Care Unit) main entrance.
4. There are two unprotected penetrations (plastic conduit and electrical wires) passing through the 2-hour fire rated barrier wall in room # L006, above the suspended ceiling, between the main Hospital and the Women's Health building.

Interview on 09/28/22 with Staff A and Staff B confirmed the above findings, conditions, and locations.

Based on record review and interview, it was determined the facility failed to ensure fire drills are conducted quarterly for the 2nd and 3rd shift's.

Findings include:

Record review during tour on 09/27/22 between 9:00 a.m. and 1:00 p.m. with Staff A (Senior Director of Operations) and Staff B (Executive Assistant) revealed the following fire drill times and dates for the 2nd and 3rd shift's:

2nd shift 3:00 p.m. - 11:00 p.m.
01/03/18 3:10 p.m.
04/24/18 4:00 p.m.
08/13/18 3:40 p.m.
not conducted
02/23/19 9:30 p.m.
05/19/19 10:00 p.m.
not conducted
11/17/19 8:00 p.m.
(2020 completed)
02/13/21 10:00 p.m.
05/11/21 9:00 p.m.
08/23/21 3:15 p.m.
not conducted
02/22/22 10:00 p.m.
not conducted
not conducted


3rd shift 11:00 p.m. - 7:00 a.m.
03/22/18 3:00 a.m.
not conducted
07/31/18 6:30 a.m.
10/01/18 1:00 a.m.
01/20/19 6:00 a.m.
04/28/19 5:00 a.m.
07/03/19 5:00 a.m.
10/28/19 12:00 a.m.
01/08/20 3:00 a.m.
Covid excused
07/27/20 6:00 a.m.
not conducted
03/29/21 6:00 a.m.
06/26/21 1:00 a.m.
09/19/21 11:30 p.m.
12/17/21 6:55 a.m.
not conducted
05/03/22 6:30 a.m.
09/21/22 6:40 a.m.

Interview on 09/28/22 with Staff A and Staff B confirmed the above findings and available documentation.

NFPA 70 National Electrical Code (2011 edition)

110.26 Spaces About Electrical Equipment.
Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(A) Working Space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26 (A) (1).
110.26 Working Space

Condition 1 condition 2
0 - 150 volts 3 ft. 3 ft.
151-600 volts 3 ft. 3 ft.

314.28 Pull and junction boxes and conduit bodies.
Boxes and conduit bodies used as pull or junction boxes shall comply with 314.28 (A) through (E).
(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible withe box or conduit body construction and suitable for the conditions of use. where used, metal covers shall comply with the grounding requirements of 250.110.

Based on observations and interview, it was determined that the facility failed to ensure one 4" x 4" metal junction box, failed to be provided with a suitable cover and the electrical wire connections failed to be contained inside the junction box.

Findings include:

Observations during tour on 09/28/22 between 10:15 a.m. and 10:30 a.m. with Staff A (Senior Director of Operations) and Staff B (Executive Assistant) revealed one 4' x 4" metal junction box, located above the suspended ceiling, directly over the PACU (Post Acute Care Unit) has multiple electrical wire connections, extending well beyond the junction box and failed to be equipped with a suitable cover to secure the electrical connections.

Interview on 09/28/22 with Staff A and Staff B confirmed the above findings and location.