HospitalInspections.org

Based on records review, the facility failed to meet the required construction type.

The findings included:

During the review of the drawings on 8/16/16 at 11:00 AM, the facilities architectural drawings dated 2/8/1994 revealed the 2nd floor building type construction was Type II (000) unprotected without an automatic sprinkler system installed.
National Fire Protection Association (NFPA) 101, 19. 1.6.2 (2000 Ed.)
National Fire Protection Association (NFPA) 101, 19. 3.5.1 (2000 Ed.)
National Fire Protection Association (NFPA) 101, 9.7.1.1*(2000 Ed.)

This finding was acknowledged by the Plant Operations Manager on 8/16/1994.

Based on observations, the facility failed to maintain the exit enclosures.

The finding included:

Observation on 8/17/16 at 9:35 AM, revealed the exit stairway by room 224 had following penetrations and improper fire stopping:

a. 2 open holes in the block wall.

b. drywall seams not properly sealed.

c. 1 inch metal conduit.

d. Blocks not sealed at roof deck.
National Fire Protection Association (NFPA) 101, 19.3.1.1 (2000 ED), NFPA 101, 8.2.5.2 (2000 ED), NFPA 101, 8.2.5.4 (2000 Ed), NFPA 101, 7.1.3.2 (2000 ED).

This finding was verified by the Plant Operations Manager during the tour on 8/17/16.

Based on records review, the facility failed to conduct all required fire drills.

The findings included:

During the records review, on 8/17/16 at 10:30 AM, the facility failed to provide documentation of 3rd shift fire drills for 2015 and 2016.
National Fire Protection Association (NFPA)101, 19.7.1.2 (2000 Ed.)

This finding was verified by the Plant Operations Manager on 8/17/16.

Based on observations, the facility failed to install the occupant notification devices in accordance with NFPA 72.

The findings included:

Observation on 8/17/16 at 10:15 AM, revealed the wall mount horn/strobe notification devices were mounted on the ceilings in the following locations:
a. by room 237.

b. by room 246.

c. by room 251.
National Fire Protection Association (NFPA) 101, 19.3.4.1 (2000 Ed.)
NFPA 101, 9.6.1.4 (2000 Ed.)
NFPA 72, 4-1.3 (1999 Ed.)

These findings were verified during the survey by the Plant Operations Manager on 8/17/16.

Based on records review, the facility failed to maintain the fire alarm system.

The findings included:

During the records review, on 8/17/16 at 10:30 AM, the facility failed to provide documentation of sensitivity test performed on the smoke detectors.
National Fire Protection Association (NFPA) 101, 19. 3.4.1(2000 Ed.)
National Fire Protection Association (NFPA) 101, 9.6.1.4 (2000 Ed.)
National Fire Protection Association (NFPA) 72, 7.3.2.1 (1999 Ed.)

This finding was verified by the Plant Operations Manager on 8/17/16.

Based on records review, the facility failed to maintain the building service equipment.

The findings included:

During the records review on 8/17/16 at 10:30 AM, the facility failed to provide documentation of the fire damper inspection.
National Fire Protection Association (NFPA) 101, 19.5.2.1 (2000 Ed.)
NFPA 101, 9.2 (2000 Ed.)
NFPA 90A, 3-4.7 (1999 Ed.)

This finding was verified during the survey by the Plant Operations Manager on 8/17/16.

National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

NFPA 221, 4.1 (2000 Ed.)
4.1* Wall Materials.
The fire resistance rating of the wall assembly shall be as required by the applicable code or standard. Assemblies shall be tested and rated in accordance with NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials.
Exception: Assemblies calculated to have equivalent fire resistance shall be permitted, provided that the calculations are based on the conditions of acceptance and the fire exposure specified in NFPA 251.

NFPA 4.2 (2000 Ed.) Penetration Seals.
All through-penetration protection systems shall be tested and rated in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through-Penetration Fire Stops, or ANSI/UL 1479, Fire Test of Through Penetration Fire Stops. The positive pressure difference between the exposed and unexposed surfaces of the test assembly shall not be less than 0.01 in. (2.5 Pa) water gauge. A through-penetration protection system shall have an F rating not less than the required fire resistance rating of the fire wall or fire barrier wall.

NFPA 221, 3.2 (2000 Ed.) Termination Points.
A fire barrier wall shall extend from the foundation or floor below to the underside of the roof or floor deck above. Any voids or gaps created by the meeting of the wall and floor below and the underside of the roof or floor deck above shall be filled with an approved material with a fire resistance rating at least equal to that of the fire wall.

Based on observations, the facility failed to maintain the 1 hour fire barrier walls.

The findings included:

1. Observations on 8/17/16 at 9:00 AM, revealed the 1 hour rated corridor walls with patient rooms 230 - 237 had the following penetrations and in-proper fire stopping:
a. 5 - 1 inch metal conduits were not sealed.

b. 18 drywall patches. (unapproved fire stop method)

c. the I beams were not sealed at the walls.

d. the walls were not sealed at the roof deck.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

2. Observations on 8/17/16 at 9:20 AM, revealed the 1 hour rated corridor walls with patient rooms 225 - 229 had the following penetrations and in-proper fire stopping:
a. 16 drywall patches.

b. the walls were sealed at the roof deck.

c. 2 - 1 1/2 inch metal conduits, 4 - 1/2 metal conduits, and 5 - 1 inch metal conduits were not sealed.

d. 7 low voltage cables without sleeves were not sealed.

e. an open 2 inch x 3 inch unused penetration and a 1 inch unused penetration.

f. the drywall seams were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

3. Observations on 8/17/16 at 9:35 AM, revealed the 1 hour rated corridor walls with patient rooms 219 - 241 had the following penetrations and in-proper fire stopping:
a. the walls were not sealed at the deck.

b. the I beams were not sealed.

c. drywall seams not sealed.

d. 5 drywall patches. (unapproved fire stop method)

e. 8 - 1 inch metal conduits and 2 - 1/2 metal conduits were not sealed.

f. 5 low voltage cables were not sealed.

g. 2 water pipes were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

4. Observations on 8/17/16 at 10: 15 AM, revealed the 1 hour fire barrier walls behind the nurses station had the following penetrations and in-proper fire stopping:
a. 2 drywall patches. (unapproved fire stop method)

b. 3 low voltage cables not sealed.

c. the walls were not sealed at the roof deck.

d. drywall seams were not sealed.

e. a 1 inch flexible conduit was not sealed and 3 - 1 inch conduits were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

5. Observations on 8/17/16 at 10: 25 AM, revealed the 1 hour fire barrier walls in the copy room had the following penetrations and in-proper fire stopping:
a. 2 drywall patches (unapproved fire stop method)

b. 5 - 1 1/2 inch metal conduits sealed with unapproved fire stop.

c. a 2 inch copper line sealed with unapproved fire stop.

d. the walls were not sealed at the deck.

e. the drywall seams were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

6. Observations on 8/17/16 at 10:35 AM, revealed the 1 hour fire barrier walls in the nurses station had the following penetrations and in-proper fire stopping:
a. 1 drywall patches (unapproved fire stop method)

b. 5 - 1 1/2 inch metal conduits sealed with unapproved fire stop.

c. 1 - 2 inch metal conduit not sealed at the opening.

d. the walls were not sealed at the deck.

e. the drywall seams were not sealed.

f. 1 low voltage cable not sleeved and not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

7. Observations on 8/17/16 at 10:42 AM, revealed the 1 hour fire barrier wall above the icemaker had the following penetrations and in-proper fire stopping:
a. a 1 1/2 inch unused penetration.

b. 2 low voltage black cables were not sleeved and not sealed.

b. 2 - 1 1/2 inch metal conduits not sealed.

c. the wall was not sealed at the deck.

e. the drywall seams were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

8. Observations on 8/17/16 at 10:45 AM, revealed the 1 hour fire barrier wall above the sink counter in the waiting area had the following penetrations and in-proper fire stopping:
a. 4 drywall patches (unapproved fire stop method)

b. 1 - 1/2 inch metal conduit, and 2 - 1 inch conduits were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

9. Observations on 8/17/16 at 10:45 AM, revealed the 1 hour fire barrier wall above room 238 had the following penetrations and in-proper fire stopping:
a. the metal framing penetrating the rated wall was not sealed.

b. the wall was not sealed at the deck.

c. the I beams were sealed with unapproved fire stop.

d. a 1 inch metal conduit not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

10. Observations on 8/17/16 at 11:51 AM, revealed the 1 hour fire barrier wall above the janitor closet 240 had an unsealed opening above the hard ceiling.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

11. Observations on 8/17/16 at 11:51 AM, revealed the 1 hour fire barrier wall above room 238 had the following penetrations and in-proper fire stopping:
a. 6 drywall patches (unapproved fire stop method)

b. 2 - 4 inch metal conduits with unapproved fire stop.

c. the wall was not sealed at the deck.

d. 4 I beams were sealed with unapproved fire stop.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

12. Observations on 8/17/16 at 11:55 AM, revealed the 1 hour fire barrier wall above the soiled utility room on the nurses station hall had the following penetrations and in-proper fire stopping:
a. 4 inch conduits, a 1 1/2 conduit was not sealed with approved fire stop.

b. the wall was not sealed at the deck.

c. yellow electrical wiring not sealed at walls.

d. 5 I beams not sealed with approved fire stop.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

13. Observations on 9/2/16 at 8:30 AM, revealed the 1 hour rated corridor walls with patient rooms 202 - 208 had the following penetrations and in-proper fire stopping:
a. 19 - 1 inch metal conduits were not sealed.

b. the walls were not sealed at the roof deck.

c. the drywall seams were not sealed.

d. the I beams were not sealed.

e. 14 drywall patches (unapproved fire stop method)

f. 2 water lines not sealed at the wall.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

14. Observations on 9/2/16 at 9:00 AM, revealed the 1 hour rated corridor walls with patient rooms 209 - 211 had the following penetrations and in-proper fire stopping:
a. 3 drywall patches. (not approved fire stop method)

b. 6 penetrations from 3 water lines running through both corridor walls.

c. 8 - 1 inch metal conduits not sealed at the wall.

d. the wall was not sealed at the deck.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.) Penetration Seals
NFPA 221, 3.2 (2000 Ed.)

15. Observations on 9/2/16 at 9:30 AM, revealed the 1 hour rated corridor walls with patient rooms 212 - 216 had the following penetrations and in-proper fire stopping:
a. the wall was not sealed at the deck.

b. 16 drywall patches. (not approved fire stop method)

c. 22 - 1 inch metal conduits not sealed at the wall.

d. the I beams were not sealed.

e. the drywall seams were not sealed.

f. 4 water lines not sealed at the wall.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

16. Observation on 9/2/16 at 8:30 AM, revealed the following penetrations above the cross corridor smoke doors by rooms 202 and 216.
a. 13 - 1 inch metal conduits sealed with unapproved fire stop

b. Unused open holes

c. 1 - 3 inch PVC pipe sealed with unapproved fire stop.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)


These findings were verified during the survey by the Plant Operations manager on 8/17/16 and on 9/2/16.

Based on observations, the facility failed to maintain electrical equipment.

The findings included:

1. Observation on 8/17/16 at 9:15 AM, revealed open junction boxes in the following areas:
a. by room 227.

b. by room 229.

c. by room 225.

d. by room 219.

e. by room 212.

National Fire Protection Association (NFPA) 101, 19.5.1 (2000 Ed.)
National Fire Protection Association (NFPA) 101, 9.1.2 (2000 Ed.)
National Fire Protection Association (NFPA) 70, 370-28 (c) (1999 Ed.)

2. Review of records on 8/17/16 at 10:30 AM, failed to provide a retention test for electrical receptacles.
National Fire Protection Association (NFPA) 99, 3-3.3.3.3. (1999 Ed.)

These findings were verified during the survey by the Plant Operations Manager on 8/17/16.

Based on records review, the facility failed to meet the required construction type.

The findings included:

During the review of the drawings on 8/16/16 at 11:00 AM, the facilities architectural drawings dated 2/8/1994 revealed the 2nd floor building type construction was Type II (000) unprotected without an automatic sprinkler system installed.
National Fire Protection Association (NFPA) 101, 19. 1.6.2 (2000 Ed.)
National Fire Protection Association (NFPA) 101, 19. 3.5.1 (2000 Ed.)
National Fire Protection Association (NFPA) 101, 9.7.1.1*(2000 Ed.)

This finding was acknowledged by the Plant Operations Manager on 8/16/1994.

Based on observations, the facility failed to maintain the exit enclosures.

The finding included:

Observation on 8/17/16 at 9:35 AM, revealed the exit stairway by room 224 had following penetrations and improper fire stopping:

a. 2 open holes in the block wall.

b. drywall seams not properly sealed.

c. 1 inch metal conduit.

d. Blocks not sealed at roof deck.
National Fire Protection Association (NFPA) 101, 19.3.1.1 (2000 ED), NFPA 101, 8.2.5.2 (2000 ED), NFPA 101, 8.2.5.4 (2000 Ed), NFPA 101, 7.1.3.2 (2000 ED).

This finding was verified by the Plant Operations Manager during the tour on 8/17/16.

Based on records review, the facility failed to conduct all required fire drills.

The findings included:

During the records review, on 8/17/16 at 10:30 AM, the facility failed to provide documentation of 3rd shift fire drills for 2015 and 2016.
National Fire Protection Association (NFPA)101, 19.7.1.2 (2000 Ed.)

This finding was verified by the Plant Operations Manager on 8/17/16.

Based on observations, the facility failed to install the occupant notification devices in accordance with NFPA 72.

The findings included:

Observation on 8/17/16 at 10:15 AM, revealed the wall mount horn/strobe notification devices were mounted on the ceilings in the following locations:
a. by room 237.

b. by room 246.

c. by room 251.
National Fire Protection Association (NFPA) 101, 19.3.4.1 (2000 Ed.)
NFPA 101, 9.6.1.4 (2000 Ed.)
NFPA 72, 4-1.3 (1999 Ed.)

These findings were verified during the survey by the Plant Operations Manager on 8/17/16.

Based on records review, the facility failed to maintain the fire alarm system.

The findings included:

During the records review, on 8/17/16 at 10:30 AM, the facility failed to provide documentation of sensitivity test performed on the smoke detectors.
National Fire Protection Association (NFPA) 101, 19. 3.4.1(2000 Ed.)
National Fire Protection Association (NFPA) 101, 9.6.1.4 (2000 Ed.)
National Fire Protection Association (NFPA) 72, 7.3.2.1 (1999 Ed.)

This finding was verified by the Plant Operations Manager on 8/17/16.

Based on records review, the facility failed to maintain the building service equipment.

The findings included:

During the records review on 8/17/16 at 10:30 AM, the facility failed to provide documentation of the fire damper inspection.
National Fire Protection Association (NFPA) 101, 19.5.2.1 (2000 Ed.)
NFPA 101, 9.2 (2000 Ed.)
NFPA 90A, 3-4.7 (1999 Ed.)

This finding was verified during the survey by the Plant Operations Manager on 8/17/16.

National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

NFPA 221, 4.1 (2000 Ed.)
4.1* Wall Materials.
The fire resistance rating of the wall assembly shall be as required by the applicable code or standard. Assemblies shall be tested and rated in accordance with NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials.
Exception: Assemblies calculated to have equivalent fire resistance shall be permitted, provided that the calculations are based on the conditions of acceptance and the fire exposure specified in NFPA 251.

NFPA 4.2 (2000 Ed.) Penetration Seals.
All through-penetration protection systems shall be tested and rated in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through-Penetration Fire Stops, or ANSI/UL 1479, Fire Test of Through Penetration Fire Stops. The positive pressure difference between the exposed and unexposed surfaces of the test assembly shall not be less than 0.01 in. (2.5 Pa) water gauge. A through-penetration protection system shall have an F rating not less than the required fire resistance rating of the fire wall or fire barrier wall.

NFPA 221, 3.2 (2000 Ed.) Termination Points.
A fire barrier wall shall extend from the foundation or floor below to the underside of the roof or floor deck above. Any voids or gaps created by the meeting of the wall and floor below and the underside of the roof or floor deck above shall be filled with an approved material with a fire resistance rating at least equal to that of the fire wall.

Based on observations, the facility failed to maintain the 1 hour fire barrier walls.

The findings included:

1. Observations on 8/17/16 at 9:00 AM, revealed the 1 hour rated corridor walls with patient rooms 230 - 237 had the following penetrations and in-proper fire stopping:
a. 5 - 1 inch metal conduits were not sealed.

b. 18 drywall patches. (unapproved fire stop method)

c. the I beams were not sealed at the walls.

d. the walls were not sealed at the roof deck.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

2. Observations on 8/17/16 at 9:20 AM, revealed the 1 hour rated corridor walls with patient rooms 225 - 229 had the following penetrations and in-proper fire stopping:
a. 16 drywall patches.

b. the walls were sealed at the roof deck.

c. 2 - 1 1/2 inch metal conduits, 4 - 1/2 metal conduits, and 5 - 1 inch metal conduits were not sealed.

d. 7 low voltage cables without sleeves were not sealed.

e. an open 2 inch x 3 inch unused penetration and a 1 inch unused penetration.

f. the drywall seams were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

3. Observations on 8/17/16 at 9:35 AM, revealed the 1 hour rated corridor walls with patient rooms 219 - 241 had the following penetrations and in-proper fire stopping:
a. the walls were not sealed at the deck.

b. the I beams were not sealed.

c. drywall seams not sealed.

d. 5 drywall patches. (unapproved fire stop method)

e. 8 - 1 inch metal conduits and 2 - 1/2 metal conduits were not sealed.

f. 5 low voltage cables were not sealed.

g. 2 water pipes were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

4. Observations on 8/17/16 at 10: 15 AM, revealed the 1 hour fire barrier walls behind the nurses station had the following penetrations and in-proper fire stopping:
a. 2 drywall patches. (unapproved fire stop method)

b. 3 low voltage cables not sealed.

c. the walls were not sealed at the roof deck.

d. drywall seams were not sealed.

e. a 1 inch flexible conduit was not sealed and 3 - 1 inch conduits were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

5. Observations on 8/17/16 at 10: 25 AM, revealed the 1 hour fire barrier walls in the copy room had the following penetrations and in-proper fire stopping:
a. 2 drywall patches (unapproved fire stop method)

b. 5 - 1 1/2 inch metal conduits sealed with unapproved fire stop.

c. a 2 inch copper line sealed with unapproved fire stop.

d. the walls were not sealed at the deck.

e. the drywall seams were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

6. Observations on 8/17/16 at 10:35 AM, revealed the 1 hour fire barrier walls in the nurses station had the following penetrations and in-proper fire stopping:
a. 1 drywall patches (unapproved fire stop method)

b. 5 - 1 1/2 inch metal conduits sealed with unapproved fire stop.

c. 1 - 2 inch metal conduit not sealed at the opening.

d. the walls were not sealed at the deck.

e. the drywall seams were not sealed.

f. 1 low voltage cable not sleeved and not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

7. Observations on 8/17/16 at 10:42 AM, revealed the 1 hour fire barrier wall above the icemaker had the following penetrations and in-proper fire stopping:
a. a 1 1/2 inch unused penetration.

b. 2 low voltage black cables were not sleeved and not sealed.

b. 2 - 1 1/2 inch metal conduits not sealed.

c. the wall was not sealed at the deck.

e. the drywall seams were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

8. Observations on 8/17/16 at 10:45 AM, revealed the 1 hour fire barrier wall above the sink counter in the waiting area had the following penetrations and in-proper fire stopping:
a. 4 drywall patches (unapproved fire stop method)

b. 1 - 1/2 inch metal conduit, and 2 - 1 inch conduits were not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

9. Observations on 8/17/16 at 10:45 AM, revealed the 1 hour fire barrier wall above room 238 had the following penetrations and in-proper fire stopping:
a. the metal framing penetrating the rated wall was not sealed.

b. the wall was not sealed at the deck.

c. the I beams were sealed with unapproved fire stop.

d. a 1 inch metal conduit not sealed.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

10. Observations on 8/17/16 at 11:51 AM, revealed the 1 hour fire barrier wall above the janitor closet 240 had an unsealed opening above the hard ceiling.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

11. Observations on 8/17/16 at 11:51 AM, revealed the 1 hour fire barrier wall above room 238 had the following penetrations and in-proper fire stopping:
a. 6 drywall patches (unapproved fire stop method)

b. 2 - 4 inch metal conduits with unapproved fire stop.

c. the wall was not sealed at the deck.

d. 4 I beams were sealed with unapproved fire stop.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

12. Observations on 8/17/16 at 11:55 AM, revealed the 1 hour fire barrier wall above the soiled utility room on the nurses station hall had the following penetrations and in-proper fire stopping:
a. 4 inch conduits, a 1 1/2 conduit was not sealed with approved fire stop.

b. the wall was not sealed at the deck.

c. yellow electrical wiring not sealed at walls.

d. 5 I beams not sealed with approved fire stop.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

13. Observations on 9/2/16 at 8:30 AM, revealed the 1 hour rated corridor walls with patient rooms 202 - 208 had the following penetrations and in-proper fire stopping:
a. 19 - 1 inch metal conduits were not sealed.

b. the walls were not sealed at the roof deck.

c. the drywall seams were not sealed.

d. the I beams were not sealed.

e. 14 drywall patches (unapproved fire stop method)

f. 2 water lines not sealed at the wall.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

14. Observations on 9/2/16 at 9:00 AM, revealed the 1 hour rated corridor walls with patient rooms 209 - 211 had the following penetrations and in-proper fire stopping:
a. 3 drywall patches. (not approved fire stop method)

b. 6 penetrations from 3 water lines running through both corridor walls.

c. 8 - 1 inch metal conduits not sealed at the wall.

d. the wall was not sealed at the deck.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.) Penetration Seals
NFPA 221, 3.2 (2000 Ed.)

15. Observations on 9/2/16 at 9:30 AM, revealed the 1 hour rated corridor walls with patient rooms 212 - 216 had the following penetrations and in-proper fire stopping:
a. the wall was not sealed at the deck.

b. 16 drywall patches. (not approved fire stop method)

c. 22 - 1 inch metal conduits not sealed at the wall.

d. the I beams were not sealed.

e. the drywall seams were not sealed.

f. 4 water lines not sealed at the wall.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)

16. Observation on 9/2/16 at 8:30 AM, revealed the following penetrations above the cross corridor smoke doors by rooms 202 and 216.
a. 13 - 1 inch metal conduits sealed with unapproved fire stop

b. Unused open holes

c. 1 - 3 inch PVC pipe sealed with unapproved fire stop.
National Fire Protection Association (NFPA) 101, 8.2.3.2.4.2
NFPA 221, 4.1 (2000 Ed.)
NFPA 221, 4.2 (2000 Ed.)
NFPA 221, 3.2 (2000 Ed.)


These findings were verified during the survey by the Plant Operations manager on 8/17/16 and on 9/2/16.

Based on observations, the facility failed to maintain electrical equipment.

The findings included:

1. Observation on 8/17/16 at 9:15 AM, revealed open junction boxes in the following areas:
a. by room 227.

b. by room 229.

c. by room 225.

d. by room 219.

e. by room 212.

National Fire Protection Association (NFPA) 101, 19.5.1 (2000 Ed.)
National Fire Protection Association (NFPA) 101, 9.1.2 (2000 Ed.)
National Fire Protection Association (NFPA) 70, 370-28 (c) (1999 Ed.)

2. Review of records on 8/17/16 at 10:30 AM, failed to provide a retention test for electrical receptacles.
National Fire Protection Association (NFPA) 99, 3-3.3.3.3. (1999 Ed.)

These findings were verified during the survey by the Plant Operations Manager on 8/17/16.