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Based on observations and interview, it was determined that the facility failed to ensure one barrier wall was maintained to form a separation between the Elevator lobby and the Surgical department suite. Two unprotected penetrations, located above the suspended ceiling, were discovered to be open through the corridor separation wall.

Findings include:

Observations during tour on 03/16/22 between 1:00 p.m. and 1:30 p.m. with Staff A (Facilities Director) and Staff B (Facilities Supervisor) revealed at least two locations with unprotected penetrations through the corridor suite separation barrier wall. These unprotected penetrations are between the 3rd floor elevator lobby and the 3rd floor Surgical Department suite.
The two locations and conditions are as follows:
1. Above the suspended ceiling, directly above the main operating suite entrance doors, has a 1-1/2" unprotected hole through the wall with 2 cable wires passing through the wall.
2. Above the suspended ceiling, on the wall directly across from the elevators, has a 6" x 6" piece of drywall that is missing and fails to be able to complete a smoke resistant barrier.

Interview on 03/16/22 with Staff A and Staff B confirmed the above findings and existing conditions and locations.

Based on record review and interview, it was determined that the facility failed to ensure that a fire watch was documented on 5 separate occasions where the fire alarm system (3rd floor zone) was shut down for at least 4 consecutive hours.

Findings include:

Record review during tour on 03/15/22 between 10:00 a.m. and 4:00 p.m. with Staff A (Facilities Director) and Staff B (Facilities Supervisor) revealed the fire alarm (shutdown) master list for April and may of 2021.
The 5 fire alarm control panel shut downs (documented) are as follows:

date: reason: location: off: on: FD notified:
04/12/21 hot work 3rd floor 7:00 a.m. - 2:55 p.m. yes
04/13/21 hot work 3rd floor 6:45 a.m. - 3:06 p.m. yes
04/22/21 electrical 8:25 a.m. - 3:28 p.m. yes
04/30/21 hot work 3rd floor 8:15 a.m. - 1:44 p.m. yes
05/04/21 P.T. project 2nd flr 7:38 a.m. - 3:30 p.m. no

Interview on 03/16/21 with Staff A and Staff B confirmed the above findings and available documentation.

NFPA 72 National Fire Alarm and Signaling Code (2010 edition)
17.5.3.1 Total Coverage. where required by laws, codes, or standards, and unless otherwise modified by 17.5.3.1.1 through 17.5.3.1.5, total coverage shall include all rooms, halls, storage areas, basements, attics, lofts, spaces above suspended ceilings, and other subdivisions and accessable spaces, as well as inside of all closets, elevator shafts, enclosed stairways, dumbwaiter shafts, and chutes.
17.7.1.11 Protection During Construction.
17.7.1.11.1 Where detectors are installed for signal initiation during construction, they shall be cleaned and verified to be operating in accordance with there listed sensativity, or they shall be replaced prior to the final commisioning of the system.

Based on record review, observations, and interview, it was determined that the facility failed to ensure smoke detection is provided in the 3rd floor construction area (approximately 5500 sq. ft.).

Findings include:

Record review during tour on 03/15/22 between 10:00 a.m. and 4:00 p.m. with Staff A (Facilities Director) and Staff B (Facilities Supervisor) revealed that 10 smoke detectors were removed from the 3rd floor area selected for a long term construction project. There failed to be any detection (rate of rise detectors, heat detectors, smoke detectors) located within the 5500 sq. ft. suite for at least the last two months and any fire or smoke condition would go unnoticed during non-construction hours for up to a possible 2 hours between security checks.

Observations and interview on 03/16/22 with Staff A and Staff B confirmed the above findings, locations and available documentation.

Based on record review, observations and interview, it was determined that the facility failed to conduct/document a fire watch or conduct/document a risk assessment for the construction area affected when they removed multiple sprinkler heads in a 3rd floor suite for a long term construction project.

Findings include:

Record review on 03/15/22 between 10:00 a.m. and 4:00 p.m. with Staff A (Facilities Director) and Staff B (Facilities Supervisor) revealed the sprinkler heads in the construction zone were removed for at least two month's without conducting a fire watch or risk assessment for the affected locations.

Observations and interview on 03/16/22 with Staff A and Staff B confirmed the above findings and locations.

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 that the facility failed to maintain at least three smoke barrier locations to resist the passage of smoke.

Findings include:

Observations during tour on 03/16/22 between 1:00 p.m. and 2:30 p.m. with Staff A (Facilities Director) and Staff B (Facilities Supervisor) revealed at least three locations with unprotected penetrations through the required smoke barrier walls. The smoke barrier walls are located on the first floor and third floor.
The three location's and conditions are as follows:
1. Above the suspended ceiling in the first floor utility corridor, behind the main Kitchen storage room and directly across from the Materials Management storage department, there is a 12" x 24" (approximately) piece of drywall removed from the wall.
2. Above the suspended ceiling on the third floor, directly over the Sleep Lab entrance, has one unprotected 1-1/2" hole with 4 fire alarm electrical wires passing through the wall.
3. Above the suspended ceiling on the third floor, above the smoke barrier doors to the Pharmacy corridor, has one 5" x 5" piece of drywall missing with 5 FMC (Flexible Metal Conduit's) passing through the smoke barrier wall.

Interview on 03/16/22 with Staff A and Staff B confirmed the above findings, locations, and conditions that will not prevent the passage of smoke.

Based on record review and interview, it was determined that the facility failed to perform one required fire drill for the 3rd shift, first quarter, of 2021.

Findings include:

Record review during tour on 03/15/22 between 10:00 a.m. and 4:00 p.m. with Staff A (Facilities Director) and Staff B (Facilities Supervisor) revealed the fire drill records for 2021 failed to include one drill.
The completed fire drill dates and times are as follows:

1st shift 7:00 a.m. - 3:00 p.m.
01/11/22 1:45 p.m.
10/27/21 11:15 a.m.
07/22/21 2:16 p.m.
04/22/21 9:32 a.m.
03/24/21 2:38 p.m.

2nd shift 3:00 p.m. - 11:00 p.m.
02/05/22 7:30 p.m.
11/15/21 11:00 p.m.
08/20/21 10:05 p.m.
05/22/21 9:05 p.m.
02/24/21 10:35 p.m.
01/10/21 9:40 p.m.

3rd shift 11:00 p.m. - 7:00 a.m.
12/11/21 3:00 a.m.
09/22/21 4:00 a.m.
06/30/21 2:29 a.m.
* NO DRILL

Interview on 03/16/21 with Staff A and Staff B confirmed the above findings and available documentation.

NFPA 241 Standard for Safeguarding Construction, Alterations, and Demolition Operations
4.13.4 Temporary Construction Barriers.
4.13.4.1 Barriers shall be provided to seperate an occupied portion of the structure from a portion of the structure under-going alteration, construction, or demolition operations when such operations have a higher level of hazard than the occupied portion of the building.
4.13.4.1.1 Barriers shall have at least a 1-hour fire resistant rating
4.13.4.1.2 Opening protectives shall have at least a 45-minute fire resistant rating (doors).

Based on observations and interview, it was determined that the facility failed to ensure that a 1-hour barrier was installed between the occupied part of the facility and the area under-going construction.

Findings include:

Observations during tour on 03/16/22 between 11:45 a.m. and 12:15 p.m. with Staff A (Facilities Director) and Staff B (Facilities Supervisor) revealed the 3rd floor construction zone, approximately 5500 sq. ft., fails to be seperated from the 3rd floor elevator lobby with a 1-hour fire resistant assembly. A plastic dust barrier was installed across the corridor.

Interview on 03/16/22 with Staff A and Staff B confirmed the above findings and barrier conditions.