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NFPA 101 Life Safety Code (2012 Edition)

7.2.2.4 Guards and handrails.
7.2.2.4.1. Handrails.
7.2.2.4.1.1 Stairs and ramps shall have handrails on both sides, unless otherwise permitted in (not applicable).
7.2.2.4.1.2 In addition to the handrails required at the sides of stairs by 7.2.2.4.1.1 both of the following provisions shall apply:
(1) For new stairs, handrails shall be provided within 30" of all portions of the required egress width.
(2) For existing stairs, handrails shall meet the following criteria:
(a) They shall be provided within 44" inches of all portions of the required egress width.
(b) Such stairs shall not have their egress capacity adjusted to a higher occupant load than permitted by the capacity factor in table 7.3.3.11 if the stairs clear width between handrails exceed 60".
7.2.2.4.2 Continuity. Required guards and handrails shall continue for the full length of each flight of stairs. At turns of new stairs, inside handrails shall be continuous between flights at landings.
7.2.2.4.3 Projections. The design of guards, handrails, and hardware for attaching handrails to guards, balusters, or walls shall be such that there are no projections that might engage loose clothing. Openings in guards shall be designed to prevent loose clothing from becoming wedged in such openings.
7.2.2.4.4.2 Existing required handrails shall not be less than 30" inches, and not more than 38" inches, above the surface of the tread, measured vertically to the top of the rail from the leading edge of the tread.
7.2.2.4.4.3 The height of required handrails that form part of a guard shall be permitted to exceed 38" inches, but shall not exceed 42" inches, measured vertically to the top of the rail from the leading edge of the tread.

Based on observations and interview, it was determined the facility failed to ensure there was one set of egress stairs, exceeding 44" inches between the existing handrail width, and creating a large opening across the stairway (6-vertical steps) without an available access to a safety handrail within the center span.

Findings include:

Observations during tour on 09/25/25 between 10:00 a.m. and 10:15 a.m. with Staff A (Director of Plant Services) revealed the second floor stairway (6-vertical steps), between the second floor Lobby and the long stairway down to the first floor Gift Shop entrance, measures 11'- 4" (eleven feet and four inches) across and (approximately) 3'-10" (three feet and ten inches) tall, and is only equipped with (two) safety handrails on the very outside ends of the stairway.

Interview on 09/25/25 between 10:00 a.m. and 10:15 a.m. with Staff A confirmed the above findings, existing safety handrail conditions, and overall stairway width of 11"- 4" between the existing safety handrails.

NFPA 101 Life Safety Code (2012 edition)
8.3 Fire barriers used to provide enclosure, subdivision, or protection under this code shall be classified in accordance with one of the following fire resistance ratings:
1. 3-hour fire resistance rating
2. 2-hour fire resistance rating
3. 1-hour fire resistance rating
4. 1/2-hour fire resistance rating

8.3.1.2 Fire barriers shall comply with one of the following:
(1) The fire barriers are continuous from 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.

8.5 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.
8.5.6.2 Penetrations for Cables. Cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or a through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

Based on observations and interview, it was determined the facility failed to ensure five (5) locations with unprotected penetrations through a rated smoke/fire barrier are appropriately sealed (fire stopped) to resist the passage of smoke or the effects from smoke or fire.

Findings include:

Observations during tour on 09/25/25 between 12:00 p.m. and 2:30 p.m. with Staff A (Director of Plant Operations), Staff B (Executive Assistant to the President/CEO) revealed the five (5) following locations, descriptions, and existing unprotected penetrations through the rated smoke or fire barrier walls:
1. Above the suspended ceiling on the 2nd floor, in the corridor directly outside the Blood Draw area #-2151 (as labeled on the floor plan presented) in the Phlebotomy suite, has one (1) unprotected penetration from a white electrical wire passing through the 1-hour fire-rated barrier wall assembly (possibly powering an automatic handi-cap door opening control).
2. Above the suspended ceiling on the 2nd floor, directly above the entrance door to the Phlebotomy suite #-2150 (as labeled on the floor plan presented), has one (1) unprotected penetration from a Flexible Metal Conduit (FMC) passing through the 1-hour fire-rated barrier wall assembly.
3. Above the suspended ceiling on the 2nd floor, in the Audio suite #-2102 (as labeled on the floor plan presented), has two (2) blue CAT-5 wires, two (2) yellow computer wires, and one (1) white electrical wire passing through a four inch x four inch (4"x 4") unprotected hole in the drywall that was removed from the 1-hour fire-rated barrier wall assembly.
4. Above the suspended ceiling on the 3rd floor, in the corridor directly outside the Soiled Utility room #-3072 (as labeled on the floor plan presented) has two (2) one and a half inch (1-1/2") copper pipes with exposed open ends into the 1-hour smoke rated barrier wall assembly.
5. Above the suspended ceiling on the 3rd floor, in the corridor directly outside the Central Services Decontamination entrance door #-3546A (as labeled on the floor plan presented) has one (1) unprotected penetration from a blue CAT-5 wire and two (2) unprotected penetrations from Flexible Metal Conduits (FMC) passing through the 1-hour smoke-rated barrier wall assembly.

Interview on 09/25/25 between 12:00 p.m. and 2:30 p.m. with Staff A and Staff B confirmed the above findings, locations, and existing unprotected barrier wall penetrations.

GFCI (Ground Fault Circuit Interrupter) outlets should be tested regularly, at least monthly, to ensure they are functioning properly and protecting against electrical hazards. The testing procedure involves pressing the "test" button on the GFCI, which should interrupt the power, and then pressing the "reset" button to restore power. If the GFCI fails to trip when the test button is pressed, it needs to be replaced.
Here's a more detailed breakdown:
1. Regular Testing:
GFCI outlets should be tested at least once a month, and more frequently in areas with high usage or where water is present.
Portable GFCI units should be tested before each use.
Testing helps ensure the GFCI is operational and can quickly interrupt power in case of a ground fault.
2. Testing Procedure:
Step 1: Reset Button: Press the reset button to restore power to the outlet.
Step 2: Plug in Device: Plug in a low-wattage device, like a lamp or nightlight, to verify the outlet is working.
Step 3: Press Test Button: Press the test button on the GFCI.
Step 4: Check for Power Interruption: The device plugged into the outlet should turn off when the test button is pressed.
Step 5: Reset Button (Again): Press the reset button again to restore power to the outlet.
Step 6: Check for Power Return: The device plugged in should turn back on.

Based on record review and interview, it was determined the facility failed to ensure GFCI (Ground Fault Circuit Interrupter) outlets are tested on a monthly basis.

Findings include:

Record review during tour on 09/24/25 between 8:00 a.m. and 11:00 a.m. with Staff A (Director of Plant Services) and Staff B (Executive Assistant to the President/CEO) revealed the facility had only been testing and documenting the GFCI (Ground Fault Circuit Interrupter) outlets on a quarterly (3-month) basis for the previous 36-months.

Interview on 09/24/25 with Staff A and Staff B confirmed the above findings and available quarterly electrical testing documentation.