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Based on observations, and confirmed by staff interview, the facility failed to provide a two-hour fire resistance rating for all assemblies and penetrations through the fire barrier.

The evidence includes:

Observation on February 3, 2010 revealed that in the fire wall separating the White and Gray Buildings adjacent to room number 000V1 there were multiple wall penetrations above the drop ceiling which were not fire stopped.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observation and confirmed by maintenance staff interview, it was determined that the facility failed to ensure that the building construction is of type II (222).

The evidence includes:

It was observed on February 2, 2010 that in the Ellison Building the fire proofing was stripped from beams above the drop ceilings near room numbers 1096 and 743.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observation on February 4, 2010 and confirmed by staff interview, it was determined that the facility failed to ensure that all parts of the building meet type II (222) construction requirements.
The evidence includes:
Observation revealed that approximately 5 feet of a structural support on the top floor, near the HVAC chillers was missing some fire proofing material.
The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 4, 2010 and confirmed by staff interview, it was determined that the facility failed to ensure that the vertical penetrations are fire stopped to maintain the integrity of the fire separation.
The evidence includes:
Observation revealed a penetration in room 804 at electrical wires which was not fire stopped.
The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 4, 2010, and confirmed by staff interview, the facility failed to ensure the exit egress doors operate in conformance with NFPA 101 Section 7.2.1.8.2 guidelines.

The evidence includes:

Observation revealed that the 7th floor south stair tower door would not automatically latch upon closure. Manual intervention was required to pull the door closed to engage the latching mechanism.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations on February 2, 2010 and staff interview, it was determined that the facility failed to ensure that the smoke barriers are capable of resisting the passage of smoke.

The evidence includes:

1. Observation revealed that in the Ellison Building a hole approximately 4 inches by 4 inches was present in the smoke barrier wall around pipe penetrations, above the drop ceiling near room number 843.

2. Observation revealed that in the Ellison Building multiple holes were present above the drop ceilings for the smoke barrier in the cross corridor wall near room numbers 606 and 219.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observation on February 2, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain the smoke barriers in conformance with NFPA 101 Section 8.3 guidelines.

The evidence includes:

Observation revealed that in the Blake Building the third floor smoke barrier wall in the vicinity of the lobby for elevator number 15 had a wall penetration above the drop ceiling which was not fire stopped.

Smoke barriers shall be constructed to provide at least a one-half hour fire resistance rating. A UL listed fire-rated sealant is required to maintain the integrity of the smoke barriers. Application of the fire rated sealant must be in full compliance with the UL listed system.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observation on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain the smoke barriers in conformance with NFPA 101 Section 8.3 guidelines.

The evidence includes:

Observation revealed that, on the 8th floor, (8-00D60 telephone data A) the smoke barrier wall had a penetration above the drop ceiling which was not fire stopped.

Smoke barriers shall be constructed to provide at least a one-half hour fire resistance rating. A UL listed fire-rated sealant is required to maintain the integrity of the smoke barriers. Application of the fire rated sealant must be in full compliance with the UL listed system.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 3, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation revealed that the double fire rated doors servicing the Gray Building metal shop storage room number 000M5 had a gap between the doors in excess of the 1/8" maximum allowance.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observation on February 8, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation revealed that the double fire rated doors in the vicinity of the environmental services room, number 013, had a gap between the doors in excess of the 1/8" maximum allowance.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observations revealed that the double fire rated doors numbers CorC120, CorC220, and CorC270 had a gap between the doors in excess of the 1/8" maximum allowance.

The facility maintenance representative confirmed the findings at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that the clearance between the fire doors between the White and Gray Buildings adjacent to room number 000V1 exceeded the 1/8" maximum allowance per NFPA 101, Section 8.3.4.1 guidelines.

2. Observation on February 3, 2010 revealed that one of the double fire doors between the White and Gray Buildings, adjacent to room number 000V1, failed to automatically latch in accordance with NFPA 101, Section 8.3.4.1 guidelines.

3. Observation on February 4, 2010 revealed that the double fire door, number 12354, between the White and Ellison Buildings on level 1, utilized fire rated nylon brushes to close the door gap, which had worn in the center, and could facilitate the passage of smoke.

4. Observation on February 4, 2010 revealed that the clearance between the double fire door, number 12352, between the White and Ellison Buildings exceeded the 1/8" maximum allowance per NFPA 101, Section 8.3.4.1 guidelines.

The facility maintenance representative confirmed the findings at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

1. Observation revealed that the soiled utility room number 221 was not provided with self-closing and latching hardware.

2. Observation revealed that the wall above the drop ceiling in the soiled utility room number 221 had multiple penetrations which were not fire stopped.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

1. Observation on February 2, 2010 revealed that in the Ellison Building the door to soiled utility room number 1729 had a gap in excess of the 1/2 inch maximum allowance between the door and the door frame when fully closed which could facilitate the passage of smoke.


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2. Observation on February 3, 2010 revealed that in the Ellison Building sub-basement the double fire rated doors servicing the high voltage room (G-3) had a gap between the doors in excess of the 1/8" maximum allowance.


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3. Observation on February 3, 2010 revealed that in the Blake Building a wood chock was used to hold open the fire door servicing the sub-basement computer storage room number 0035B.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observation on February 8, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

Observation revealed that the soiled utility room was not provided with self-closing and latching hardware.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed in accordance with NFPA 101 Section 19.3.2.1 guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that in electric room, number M0008, multiple wall penetrations were not fire stopped.

2. Observation on February 3, 2010 revealed that in the high voltage electrical room, number 063, multiple wall penetrations were not fire stopped.

3. Observation on February 3, 2010 revealed that the fire sprinkler pipe wall penetration servicing electrical room, number 000M6, was not fire stopped.

4. Observation on February 3, 2010 revealed that in room, number 000D1, multiple wall penetrations were not fire stopped.


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5. Observation on February 4, 2010 revealed that the door servicing room number 214, X-ray was held open by a stool.

The facility maintenance representatives confirmed the findings at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

Observation on February 8, 2010 revealed that the soiled utility room was not provided with self-closing and latching hardware.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

Observation revealed that the wall above the drop ceiling between room number 1EN3 and the exit access corridor had a wall penetration to the side of an HVAC return air duct which was not fire stopped.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations on February 4, 2010 and confirmed by staff interview, it was determined that the facility failed to ensure that the exits are in accordance with NFPA 101, Section 21.2.4.1 guidelines.
The evidence includes:
1. Observation revealed that there was a wall penetration in the 7th floor stairway 700S02 above the drop ceiling patched with painter's tape, which was not fire stopped.
2. Observation revealed that the 5th floor south stairway, near room 500M1, was not properly fire stopped.
3. Observation revealed that the second floor north stairway near the service elevator was not properly fire stopped.
The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations on February 3, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that the exit access corridors are free of obstructions at all times.

The evidence includes:

Exit access corridors on the 7th, 11th, 13th & 14th floors were utilized as computer and/or charting stations.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the exit access corridors are free of obstructions at all times.

The evidence includes:

1. Observations on February 2 & 3 revealed in the Ellison Building that, on the 6th, 7th, 11th, 16th, 17th, 18th, 21st & 23rd floors, the exit access corridors were being used for storage of medical equipment, charting rooms and battery charging areas. In addition, retractable medical charts were found extended into the corridors.


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2. Observation on February 3, 2010 revealed in the Blake Building that the sub-basement exit access corridor in the vicinity of stairway 4 was obstructed by storage of a chair and wheelchair.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the exit access corridors are free of obstructions at all times.

The evidence includes:

Observation on February 4, 2010 revealed that the 6th floor exit access corridor in the vicinity of electrical closet number M40 was obstructed by a pallet with boxes.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 2, 2010, and confirmed by staff interview, exit signs are not provided as required in conformance with NFPA 101 Section 7.10.1.2. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

The evidence includes:

Observation revealed that there was no "EXIT" sign on the 13th floor in the vicinity of room numbers 1372 and 1373 to provide direction to exit access.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observation on February 4, 2010, and confirmed by staff interview, exit signs are not provided as required in conformance with NFPA 101 Section 7.10.1.2. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

The evidence includes:

Observation revealed that the "EXIT" sign in room 345 did not provide direction to exit access.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observation on February 2, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that all smoke detectors are installed in accordance with the manufacturer's specifications and/or NFPA 101 Section 9.6.1.3 and NFPA 72 guidelines.

The evidence includes:

Observation in the Blake Building revealed that the smoke detector servicing the soiled utility room number 1191 was dislodged from its base.

The facility maintenance representative confirmed the finding at the time of the survey.

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Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system provides complete coverage for all portions of the building in accordance with NFPA 13 guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that a former electrical room in the Gray Building sub-basement was used for the storage of combustibles and was not provided with fire sprinkler protection.

2. Observation on February 3, 2010 revealed that room number 635 was not provided with fire sprinkler protection.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system provides complete coverage for all portions of the building in accordance with NFPA 13 guidelines.

The evidence includes:
1. Observation revealed that the areas across room numbers 221H and 221G was not provided with fire sprinkler protection.
2. Observation revealed that the electrical room in the lobby of the lower level, across from room number 027 was not provided with fire sprinkler protection.
The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system provides complete coverage for all portions of the building in accordance with NFPA 13 guidelines.

The evidence includes:

1. Observations in the Ellison Building on February 2, 2010 revealed that closet room numbers 2301L and 2301K were not provided with fire sprinkler protection.

2. Observation in the Ellison Building on February 3, 2010 revealed that the main electrical switch board room, the G3 electrical room and the transfer switch room were not provided with fire sprinkler protection.


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3. Observation in the Blake Building on February 2, 2010 revealed that the environmental services room number 700J4 was not provided with fire sprinkler protection.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observations on February 3, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system provides complete coverage for all portions of the building in accordance with NFPA 13 guidelines.

The evidence includes:

1. Observation revealed that the HVAC air handling unit room number M022 was not provided with fire sprinkler protection.


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2. Observation revealed that storage closet room number 1405D was not provided with fire sprinkler protection.

3. Observation revealed that the electrical closet on the 6th floor in the vicinity of the Nursing Director's office was not provided with fire sprinkler protection.

The facility maintenance representatives confirmed the findings at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system is maintained in accordance with NFPA 25 guidelines.

The evidence includes:

1. Observation on February 2, 2010 in the Ellison Building revealed that the standpipe servicing the heliport had a cracked valve bonnet.

2. Observation on February 3, 2010 in the Ellison Building revealed that in the main kitchen food preparation area, two fire sprinkler heads had a buildup of grease, grime and lint on their fusible links.

3. Observation on February 2, 2010 in the Blake Building revealed that the fire sprinkler head servicing the storage closet in the vicinity of room number 996 was obstructed by the improper storage of materials.

4. Observation on February 2, 2010 in the Blake Building revealed that the Fire Department corridor extension connection (FE0061) was missing a protective cap.

5. Observation on February 2, 2010 in the Blake Building revealed that the fire sprinkler head servicing the janitor's closet room number 200J5 was obstructed by improper storage of materials.

6. Observation on February 3, 2010 in the Blake Building revealed that the fire sprinkler heads servicing the storage closet were obstructed by storage materials.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observation, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system is maintained in accordance with NFPA 25 guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that the fire sprinkler head in closet number 410 was obstructed by insulation.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system is maintained in accordance with NFPA 25 guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that the fire sprinkler head in the 14th floor closet above the laundry chute had an accumulation of lint and dirt.

2. Observation on February 3, 2010 revealed that the fire sprinkler head in closet number 1200J was obstructed by high piled storage within 10 inches of the head.

3. Observation on February 3, 2010 revealed that the fire sprinkler head in closet number 1100J1 was obstructed by high piled storage within 6 inches of the head.

4. Observation on February 3, 2010 revealed that the fire sprinkler head in closet number 645C was obstructed by high piled storage within 8 inches of the head.

5. Observation on February 3, 2010 revealed that two fire sprinkler heads in room number 000V1 were obstructed by high piled storage.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observation, and confirmed by staff interview, the facility failed to inspect portable fire extinguishers as required. NFPA #10, Sections 4.3.1 & 4.3.2 require fire extinguishers to be inspected when initially placed in service and thereafter at approximately 30-day intervals.

The evidence includes:

Observation in the Blake Building on February 2, 2010 revealed that the two fire extinguishers servicing the vestibule to the helicopter pad were last inspected on August 2009.

The facility's maintenance representative confirmed the finding at the time of the survey.

Based on observation, and confirmed by staff interview, the facility failed to inspect portable fire extinguishers as required. NFPA #10, Sections 4.3.1 & 4.3.2 require fire extinguishers to be inspected when initially placed in service and thereafter at approximately 30-day intervals.

The evidence includes:

Observation on February 3, 2010 revealed that a fire extinguisher number FE1640 servicing the Bigelow Amphitheatre was last inspected on December 2009.

The facility's maintenance representative confirmed the finding at the time of the survey.

Based on observation, and confirmed by staff interview, it was determined that the facility failed to maintain the standards provided in the smoking regulations.

The evidence includes:

Observation on February 3, 2010 revealed that, at the Blake Building exterior receiving dock exit stairway, a large quantity of cigarette butts and ashes were discarded on the ground in a "No Smoking" area.

The facility maintenance representative confirmed the finding at the time of the survey.

Observation on February 3, 2010 revealed that the facility failed to maintain the fire resistive construction of the laundry chute in accordance with NFPA guidelines.

NFPA 82 requires that the openings to the chute be protected by an approved automatic-closing or self-closing 1 hour fire door suitable for a Class B opening.

The evidence includes:

Observations revealed that the laundry chute door was obstructed by a continuous accumulation of soiled linen bags extending from a receiving cart to within the laundry chute.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 3, 2010 and confirmed by staff interview, it was determined that the facility failed to ensure that medical gases are installed in accordance with NFPA 99 guidelines.

The evidence includes:

A medical gas valve on the north side of the building was not labeled.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation, and confirmed by staff interview, the facility failed to properly store medical gases. NFPA 99, Sections 16.3.8.1, 8.3.1.11.2(h), and 4.3.5.2.1(b)27 requires freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart.

The evidence includes:

Observation on February 4, 2010 revealed that in room number 8-314 the oxygen cylinder storage rack obstructed the door swing.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations, and confirmed by staff interview, the facility failed to properly store medical gases. NFPA 99, Sections 16.3.8.1, 8.3.1.11.2(h), and 4.3.5.2.1(b)27 requires freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart.

The evidence includes:

Observation on February 2, 2010 in the Blake Building revealed two unsecured (not in a stand or rack) medical gas cylinders on the floor in the 5th floor machine room mixed gas storage area.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to assure that the utilities servicing the facility are in compliance with NFPA 101 Section 9.1 guidelines. Electrical wiring and equipment installations shall be in conformance with NFPA #70, "National Electrical Code".

The evidence includes:

1. Observation revealed that, in room number 348, a speaker was dislodged from the ceiling.

2. Observation revealed that, in room number 348, there was a large hole in the plastic lens of a ceiling mounted light fixture.

3. Observation revealed that, in the machine room, the protective cover was missing from a communication junction box.

The facility of maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to assure that the utilities servicing the facility are in compliance with NFPA 101 Section 9.1 guidelines. Electrical wiring and equipment installations shall be in conformance with NFPA #70, "National Electrical Code".

The evidence includes:

Observation on February 2, 2010 in the Blake Building revealed that a protective cover was missing from Trans Logic Communication junction box.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observations, and confirmed by staff interview, the facility failed to provide a two-hour fire resistance rating for all assemblies and penetrations through the fire barrier.

The evidence includes:

Observation on February 3, 2010 revealed that in the fire wall separating the White and Gray Buildings adjacent to room number 000V1 there were multiple wall penetrations above the drop ceiling which were not fire stopped.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observation and confirmed by maintenance staff interview, it was determined that the facility failed to ensure that the building construction is of type II (222).

The evidence includes:

It was observed on February 2, 2010 that in the Ellison Building the fire proofing was stripped from beams above the drop ceilings near room numbers 1096 and 743.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observation on February 4, 2010 and confirmed by staff interview, it was determined that the facility failed to ensure that all parts of the building meet type II (222) construction requirements.
The evidence includes:
Observation revealed that approximately 5 feet of a structural support on the top floor, near the HVAC chillers was missing some fire proofing material.
The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 4, 2010 and confirmed by staff interview, it was determined that the facility failed to ensure that the vertical penetrations are fire stopped to maintain the integrity of the fire separation.
The evidence includes:
Observation revealed a penetration in room 804 at electrical wires which was not fire stopped.
The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 4, 2010, and confirmed by staff interview, the facility failed to ensure the exit egress doors operate in conformance with NFPA 101 Section 7.2.1.8.2 guidelines.

The evidence includes:

Observation revealed that the 7th floor south stair tower door would not automatically latch upon closure. Manual intervention was required to pull the door closed to engage the latching mechanism.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations on February 2, 2010 and staff interview, it was determined that the facility failed to ensure that the smoke barriers are capable of resisting the passage of smoke.

The evidence includes:

1. Observation revealed that in the Ellison Building a hole approximately 4 inches by 4 inches was present in the smoke barrier wall around pipe penetrations, above the drop ceiling near room number 843.

2. Observation revealed that in the Ellison Building multiple holes were present above the drop ceilings for the smoke barrier in the cross corridor wall near room numbers 606 and 219.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observation on February 2, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain the smoke barriers in conformance with NFPA 101 Section 8.3 guidelines.

The evidence includes:

Observation revealed that in the Blake Building the third floor smoke barrier wall in the vicinity of the lobby for elevator number 15 had a wall penetration above the drop ceiling which was not fire stopped.

Smoke barriers shall be constructed to provide at least a one-half hour fire resistance rating. A UL listed fire-rated sealant is required to maintain the integrity of the smoke barriers. Application of the fire rated sealant must be in full compliance with the UL listed system.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observation on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain the smoke barriers in conformance with NFPA 101 Section 8.3 guidelines.

The evidence includes:

Observation revealed that, on the 8th floor, (8-00D60 telephone data A) the smoke barrier wall had a penetration above the drop ceiling which was not fire stopped.

Smoke barriers shall be constructed to provide at least a one-half hour fire resistance rating. A UL listed fire-rated sealant is required to maintain the integrity of the smoke barriers. Application of the fire rated sealant must be in full compliance with the UL listed system.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 3, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation revealed that the double fire rated doors servicing the Gray Building metal shop storage room number 000M5 had a gap between the doors in excess of the 1/8" maximum allowance.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observation on February 8, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observation revealed that the double fire rated doors in the vicinity of the environmental services room, number 013, had a gap between the doors in excess of the 1/8" maximum allowance.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

Observations revealed that the double fire rated doors numbers CorC120, CorC220, and CorC270 had a gap between the doors in excess of the 1/8" maximum allowance.

The facility maintenance representative confirmed the findings at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to maintain smoke barrier doors in conformance with NFPA guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that the clearance between the fire doors between the White and Gray Buildings adjacent to room number 000V1 exceeded the 1/8" maximum allowance per NFPA 101, Section 8.3.4.1 guidelines.

2. Observation on February 3, 2010 revealed that one of the double fire doors between the White and Gray Buildings, adjacent to room number 000V1, failed to automatically latch in accordance with NFPA 101, Section 8.3.4.1 guidelines.

3. Observation on February 4, 2010 revealed that the double fire door, number 12354, between the White and Ellison Buildings on level 1, utilized fire rated nylon brushes to close the door gap, which had worn in the center, and could facilitate the passage of smoke.

4. Observation on February 4, 2010 revealed that the clearance between the double fire door, number 12352, between the White and Ellison Buildings exceeded the 1/8" maximum allowance per NFPA 101, Section 8.3.4.1 guidelines.

The facility maintenance representative confirmed the findings at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

1. Observation revealed that the soiled utility room number 221 was not provided with self-closing and latching hardware.

2. Observation revealed that the wall above the drop ceiling in the soiled utility room number 221 had multiple penetrations which were not fire stopped.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

1. Observation on February 2, 2010 revealed that in the Ellison Building the door to soiled utility room number 1729 had a gap in excess of the 1/2 inch maximum allowance between the door and the door frame when fully closed which could facilitate the passage of smoke.


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2. Observation on February 3, 2010 revealed that in the Ellison Building sub-basement the double fire rated doors servicing the high voltage room (G-3) had a gap between the doors in excess of the 1/8" maximum allowance.


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3. Observation on February 3, 2010 revealed that in the Blake Building a wood chock was used to hold open the fire door servicing the sub-basement computer storage room number 0035B.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observation on February 8, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

Observation revealed that the soiled utility room was not provided with self-closing and latching hardware.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed in accordance with NFPA 101 Section 19.3.2.1 guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that in electric room, number M0008, multiple wall penetrations were not fire stopped.

2. Observation on February 3, 2010 revealed that in the high voltage electrical room, number 063, multiple wall penetrations were not fire stopped.

3. Observation on February 3, 2010 revealed that the fire sprinkler pipe wall penetration servicing electrical room, number 000M6, was not fire stopped.

4. Observation on February 3, 2010 revealed that in room, number 000D1, multiple wall penetrations were not fire stopped.


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5. Observation on February 4, 2010 revealed that the door servicing room number 214, X-ray was held open by a stool.

The facility maintenance representatives confirmed the findings at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

Observation on February 8, 2010 revealed that the soiled utility room was not provided with self-closing and latching hardware.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that hazardous areas are properly enclosed.

The evidence includes:

Observation revealed that the wall above the drop ceiling between room number 1EN3 and the exit access corridor had a wall penetration to the side of an HVAC return air duct which was not fire stopped.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations on February 4, 2010 and confirmed by staff interview, it was determined that the facility failed to ensure that the exits are in accordance with NFPA 101, Section 21.2.4.1 guidelines.
The evidence includes:
1. Observation revealed that there was a wall penetration in the 7th floor stairway 700S02 above the drop ceiling patched with painter's tape, which was not fire stopped.
2. Observation revealed that the 5th floor south stairway, near room 500M1, was not properly fire stopped.
3. Observation revealed that the second floor north stairway near the service elevator was not properly fire stopped.
The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations on February 3, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that the exit access corridors are free of obstructions at all times.

The evidence includes:

Exit access corridors on the 7th, 11th, 13th & 14th floors were utilized as computer and/or charting stations.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the exit access corridors are free of obstructions at all times.

The evidence includes:

1. Observations on February 2 & 3 revealed in the Ellison Building that, on the 6th, 7th, 11th, 16th, 17th, 18th, 21st & 23rd floors, the exit access corridors were being used for storage of medical equipment, charting rooms and battery charging areas. In addition, retractable medical charts were found extended into the corridors.


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2. Observation on February 3, 2010 revealed in the Blake Building that the sub-basement exit access corridor in the vicinity of stairway 4 was obstructed by storage of a chair and wheelchair.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the exit access corridors are free of obstructions at all times.

The evidence includes:

Observation on February 4, 2010 revealed that the 6th floor exit access corridor in the vicinity of electrical closet number M40 was obstructed by a pallet with boxes.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 2, 2010, and confirmed by staff interview, exit signs are not provided as required in conformance with NFPA 101 Section 7.10.1.2. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

The evidence includes:

Observation revealed that there was no "EXIT" sign on the 13th floor in the vicinity of room numbers 1372 and 1373 to provide direction to exit access.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observation on February 4, 2010, and confirmed by staff interview, exit signs are not provided as required in conformance with NFPA 101 Section 7.10.1.2. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

The evidence includes:

Observation revealed that the "EXIT" sign in room 345 did not provide direction to exit access.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observation on February 2, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that all smoke detectors are installed in accordance with the manufacturer's specifications and/or NFPA 101 Section 9.6.1.3 and NFPA 72 guidelines.

The evidence includes:

Observation in the Blake Building revealed that the smoke detector servicing the soiled utility room number 1191 was dislodged from its base.

The facility maintenance representative confirmed the finding at the time of the survey.

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Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system provides complete coverage for all portions of the building in accordance with NFPA 13 guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that a former electrical room in the Gray Building sub-basement was used for the storage of combustibles and was not provided with fire sprinkler protection.

2. Observation on February 3, 2010 revealed that room number 635 was not provided with fire sprinkler protection.

The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system provides complete coverage for all portions of the building in accordance with NFPA 13 guidelines.

The evidence includes:
1. Observation revealed that the areas across room numbers 221H and 221G was not provided with fire sprinkler protection.
2. Observation revealed that the electrical room in the lobby of the lower level, across from room number 027 was not provided with fire sprinkler protection.
The facility maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system provides complete coverage for all portions of the building in accordance with NFPA 13 guidelines.

The evidence includes:

1. Observations in the Ellison Building on February 2, 2010 revealed that closet room numbers 2301L and 2301K were not provided with fire sprinkler protection.

2. Observation in the Ellison Building on February 3, 2010 revealed that the main electrical switch board room, the G3 electrical room and the transfer switch room were not provided with fire sprinkler protection.


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3. Observation in the Blake Building on February 2, 2010 revealed that the environmental services room number 700J4 was not provided with fire sprinkler protection.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observations on February 3, 2010, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system provides complete coverage for all portions of the building in accordance with NFPA 13 guidelines.

The evidence includes:

1. Observation revealed that the HVAC air handling unit room number M022 was not provided with fire sprinkler protection.


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2. Observation revealed that storage closet room number 1405D was not provided with fire sprinkler protection.

3. Observation revealed that the electrical closet on the 6th floor in the vicinity of the Nursing Director's office was not provided with fire sprinkler protection.

The facility maintenance representatives confirmed the findings at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system is maintained in accordance with NFPA 25 guidelines.

The evidence includes:

1. Observation on February 2, 2010 in the Ellison Building revealed that the standpipe servicing the heliport had a cracked valve bonnet.

2. Observation on February 3, 2010 in the Ellison Building revealed that in the main kitchen food preparation area, two fire sprinkler heads had a buildup of grease, grime and lint on their fusible links.

3. Observation on February 2, 2010 in the Blake Building revealed that the fire sprinkler head servicing the storage closet in the vicinity of room number 996 was obstructed by the improper storage of materials.

4. Observation on February 2, 2010 in the Blake Building revealed that the Fire Department corridor extension connection (FE0061) was missing a protective cap.

5. Observation on February 2, 2010 in the Blake Building revealed that the fire sprinkler head servicing the janitor's closet room number 200J5 was obstructed by improper storage of materials.

6. Observation on February 3, 2010 in the Blake Building revealed that the fire sprinkler heads servicing the storage closet were obstructed by storage materials.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observation, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system is maintained in accordance with NFPA 25 guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that the fire sprinkler head in closet number 410 was obstructed by insulation.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to ensure that the fire sprinkler system is maintained in accordance with NFPA 25 guidelines.

The evidence includes:

1. Observation on February 3, 2010 revealed that the fire sprinkler head in the 14th floor closet above the laundry chute had an accumulation of lint and dirt.

2. Observation on February 3, 2010 revealed that the fire sprinkler head in closet number 1200J was obstructed by high piled storage within 10 inches of the head.

3. Observation on February 3, 2010 revealed that the fire sprinkler head in closet number 1100J1 was obstructed by high piled storage within 6 inches of the head.

4. Observation on February 3, 2010 revealed that the fire sprinkler head in closet number 645C was obstructed by high piled storage within 8 inches of the head.

5. Observation on February 3, 2010 revealed that two fire sprinkler heads in room number 000V1 were obstructed by high piled storage.

The facility maintenance representatives confirmed the observations at the time of the survey.

Based on observation, and confirmed by staff interview, the facility failed to inspect portable fire extinguishers as required. NFPA #10, Sections 4.3.1 & 4.3.2 require fire extinguishers to be inspected when initially placed in service and thereafter at approximately 30-day intervals.

The evidence includes:

Observation in the Blake Building on February 2, 2010 revealed that the two fire extinguishers servicing the vestibule to the helicopter pad were last inspected on August 2009.

The facility's maintenance representative confirmed the finding at the time of the survey.

Based on observation, and confirmed by staff interview, the facility failed to inspect portable fire extinguishers as required. NFPA #10, Sections 4.3.1 & 4.3.2 require fire extinguishers to be inspected when initially placed in service and thereafter at approximately 30-day intervals.

The evidence includes:

Observation on February 3, 2010 revealed that a fire extinguisher number FE1640 servicing the Bigelow Amphitheatre was last inspected on December 2009.

The facility's maintenance representative confirmed the finding at the time of the survey.

Based on observation, and confirmed by staff interview, it was determined that the facility failed to maintain the standards provided in the smoking regulations.

The evidence includes:

Observation on February 3, 2010 revealed that, at the Blake Building exterior receiving dock exit stairway, a large quantity of cigarette butts and ashes were discarded on the ground in a "No Smoking" area.

The facility maintenance representative confirmed the finding at the time of the survey.

Observation on February 3, 2010 revealed that the facility failed to maintain the fire resistive construction of the laundry chute in accordance with NFPA guidelines.

NFPA 82 requires that the openings to the chute be protected by an approved automatic-closing or self-closing 1 hour fire door suitable for a Class B opening.

The evidence includes:

Observations revealed that the laundry chute door was obstructed by a continuous accumulation of soiled linen bags extending from a receiving cart to within the laundry chute.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation on February 3, 2010 and confirmed by staff interview, it was determined that the facility failed to ensure that medical gases are installed in accordance with NFPA 99 guidelines.

The evidence includes:

A medical gas valve on the north side of the building was not labeled.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observation, and confirmed by staff interview, the facility failed to properly store medical gases. NFPA 99, Sections 16.3.8.1, 8.3.1.11.2(h), and 4.3.5.2.1(b)27 requires freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart.

The evidence includes:

Observation on February 4, 2010 revealed that in room number 8-314 the oxygen cylinder storage rack obstructed the door swing.

The facility maintenance representative confirmed the observation at the time of the survey.

Based on observations, and confirmed by staff interview, the facility failed to properly store medical gases. NFPA 99, Sections 16.3.8.1, 8.3.1.11.2(h), and 4.3.5.2.1(b)27 requires freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart.

The evidence includes:

Observation on February 2, 2010 in the Blake Building revealed two unsecured (not in a stand or rack) medical gas cylinders on the floor in the 5th floor machine room mixed gas storage area.

The facility maintenance representative confirmed the finding at the time of the survey.

Based on observations on February 4, 2010, and confirmed by staff interview, it was determined that the facility failed to assure that the utilities servicing the facility are in compliance with NFPA 101 Section 9.1 guidelines. Electrical wiring and equipment installations shall be in conformance with NFPA #70, "National Electrical Code".

The evidence includes:

1. Observation revealed that, in room number 348, a speaker was dislodged from the ceiling.

2. Observation revealed that, in room number 348, there was a large hole in the plastic lens of a ceiling mounted light fixture.

3. Observation revealed that, in the machine room, the protective cover was missing from a communication junction box.

The facility of maintenance representative confirmed the observations at the time of the survey.

Based on observations, and confirmed by staff interview, it was determined that the facility failed to assure that the utilities servicing the facility are in compliance with NFPA 101 Section 9.1 guidelines. Electrical wiring and equipment installations shall be in conformance with NFPA #70, "National Electrical Code".

The evidence includes:

Observation on February 2, 2010 in the Blake Building revealed that a protective cover was missing from Trans Logic Communication junction box.

The facility maintenance representative confirmed the finding at the time of the survey.