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Based on observations the facility failed to provide the required one-half hour fire resistance rating for smoke barrier walls in an existing sprinkled facility. Smoke barriers shall be continuous from outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier. All required smoke barrier walls shall be constructed with a fire resistance rating of not less than ? hour.
NFPA 101, Life Safety Code, Chapter 19, Section 19.3.7.

Findings Include;

While inspecting smoke barrier walls on March 17 through 18, 2011. The surveyor observed the following smoke barriers walls with unsealed penetrations throughout.
1. The smoke barrier wall located in the 3rd floor elevator lobby across from the central nurses station was observed with a section of wall (3 feet long) not constructed to the roof deck above.
2. The smoke barrier wall located in the 2nd floor ICU electrical room was observed without the required self closing hardware on the door assembly.
3. The smoke barrier wall located inside the 2nd floor on call room was observed without the required self closing hardware on the door assembly.
4. The smoke barrier wall across from the 2nd floor scrub area was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
5. The smoke barrier located on the 1st floor back wall of recovery area was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
6. The smoke barrier located on the 1st floor outpatient lab was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
7. The smoke barrier wall located inside the 1st floor on communications closet #4 was observed without the required self closing hardware on the door assembly.
8. The smoke barrier located on the 1st floor human resources / cafeteria was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
9. The smoke barrier located on the 1st floor Pharmacy storage was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
10. The smoke barrier located on the 1st floor surgery waiting area was observed with a section of wall (5 feet long) not constructed to the roof deck above.

These deficient practices have the potential of affecting 6 of the 10 smoke compartments located throughout the building. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 1 hour fire resistance rating for stairways in a fully sprinkled facility. Openings through floors, such as stairways shall be enclosed with a fire barrier wall. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating. NFPA 101, Life Safety Code, Chapter 19, Section 19.3.1.1, Chapter 8, Section 8.2.5.

Findings Included;

While inspecting exit components on March 17, 2011 at 10:50 a.m., the surveyor observed unsealed penetrations and/or unfinished construction in the following stairways.
1. 4C stairway located on the 4th floor was observed with unsealed penetrations and exposed studs.
2. LDR stairway located on the 2nd floor was observed with unsealed penetrations and exposed studs.

These deficient practices have the potential of affecting 2 of the 4 stairways located throughout the building. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to maintain a test there fire alarm system in accordance with NFPA 72. Doors located in the means of egress are permitted to be locked as long as adequate provisions are made for the rapid removal of occupants by the remote control of lock, keying of all locks carried by staff at all times. NFPA 101, Life Safety Code, Chapter 19, Section 19.2.2.2.

Findings Include;

While inspecting the fire alarm system on March 17, 2011 the surveyor observed the magnetic locks located on the 1st floor E.D. entrance doors did not release with the fire alarm system.

This deficient practice has the potential of affecting the entire E.D. suite. The maintenance director and the administrator were notified during the survey as well as the exit conference.

Based on observations the facility failed to protect there electrical transformers in accordance with NFPA 70. Transformers installed indoors and rated 112-1/2 kVA or less shall have a separation of at least 12 inches from combustible materials unless separated from the combustible material by a fire resistant barrier. NFPA 70, National Electrical Code, Article 450-21 (a) Transformers installed indoors and rated over 112-1/2 kVA shall be installed in a transformer room of fire resistant construction. The term fire resistant means a construction having a minimum fire rating of 1 hour. NFPA 70, National Electrical Code, Article 450-21 (b).

Findings Include;

While inspecting electrical equipment rooms on March 17-18, 2011, the surveyor observed several storage rooms/electrical rooms housing transformers without the required fire rated construction.
1. 4th floor electrical room across from public restrooms behind central nurses station was observed housing (2) 90 kVA transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
2. 3rd floor electrical room across from public restrooms behind central nurses station was observed housing (2) 90 kVA transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
3. 2nd floor electrical room across from public restrooms behind central nurses station was observed housing (1) 112 kVA transformers and (1) 75 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
4. 3rd floor electrical room across from public restrooms behind central nurses station was observed housing (2) 90 kVA transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
5. 2nd floor electrical room across from public restrooms behind central nurses station was observed housing (1) 112 kVA transformers and (1) 75 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
6. 1st floor electrical room #15 was observed housing (1) 150 kVA transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
7. 1st floor electrical room #13 was observed housing (1) 90kva transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
8. 1st floor electrical room #11 was observed housing (1) 150 kVA transformers, (1) 75 kVA transformer, and (1) 40 kVA transformer. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)

This deficient practice has the potential of affecting 8 of 10 smoke compartments. The administrator and the maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required one-half hour fire resistance rating for smoke barrier walls in an existing sprinkled facility. Smoke barriers shall be continuous from outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier. All required smoke barrier walls shall be constructed with a fire resistance rating of not less than ? hour.
NFPA 101, Life Safety Code, Chapter 19, Section 19.3.7.

Findings Include;

While inspecting smoke barrier walls on March 17 through 18, 2011. The surveyor observed the following smoke barriers walls with unsealed penetrations throughout.
1. The smoke barrier wall located in the 3rd floor elevator lobby across from the central nurses station was observed with a section of wall (3 feet long) not constructed to the roof deck above.
2. The smoke barrier wall located in the 2nd floor ICU electrical room was observed without the required self closing hardware on the door assembly.
3. The smoke barrier wall located inside the 2nd floor on call room was observed without the required self closing hardware on the door assembly.
4. The smoke barrier wall across from the 2nd floor scrub area was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
5. The smoke barrier located on the 1st floor back wall of recovery area was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
6. The smoke barrier located on the 1st floor outpatient lab was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
7. The smoke barrier wall located inside the 1st floor on communications closet #4 was observed without the required self closing hardware on the door assembly.
8. The smoke barrier located on the 1st floor human resources / cafeteria was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
9. The smoke barrier located on the 1st floor Pharmacy storage was observed with unsealed penetrations. (Expansion Joint 4 inches wide extending from top of lay in ceiling to roof deck)
10. The smoke barrier located on the 1st floor surgery waiting area was observed with a section of wall (5 feet long) not constructed to the roof deck above.

These deficient practices have the potential of affecting 6 of the 10 smoke compartments located throughout the building. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to provide the required 1 hour fire resistance rating for stairways in a fully sprinkled facility. Openings through floors, such as stairways shall be enclosed with a fire barrier wall. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating. NFPA 101, Life Safety Code, Chapter 19, Section 19.3.1.1, Chapter 8, Section 8.2.5.

Findings Included;

While inspecting exit components on March 17, 2011 at 10:50 a.m., the surveyor observed unsealed penetrations and/or unfinished construction in the following stairways.
1. 4C stairway located on the 4th floor was observed with unsealed penetrations and exposed studs.
2. LDR stairway located on the 2nd floor was observed with unsealed penetrations and exposed studs.

These deficient practices have the potential of affecting 2 of the 4 stairways located throughout the building. The administrator and the maintenance director were notified during the survey as well as in the exit conference.

Based on observations the facility failed to maintain a test there fire alarm system in accordance with NFPA 72. Doors located in the means of egress are permitted to be locked as long as adequate provisions are made for the rapid removal of occupants by the remote control of lock, keying of all locks carried by staff at all times. NFPA 101, Life Safety Code, Chapter 19, Section 19.2.2.2.

Findings Include;

While inspecting the fire alarm system on March 17, 2011 the surveyor observed the magnetic locks located on the 1st floor E.D. entrance doors did not release with the fire alarm system.

This deficient practice has the potential of affecting the entire E.D. suite. The maintenance director and the administrator were notified during the survey as well as the exit conference.

Based on observations the facility failed to protect there electrical transformers in accordance with NFPA 70. Transformers installed indoors and rated 112-1/2 kVA or less shall have a separation of at least 12 inches from combustible materials unless separated from the combustible material by a fire resistant barrier. NFPA 70, National Electrical Code, Article 450-21 (a) Transformers installed indoors and rated over 112-1/2 kVA shall be installed in a transformer room of fire resistant construction. The term fire resistant means a construction having a minimum fire rating of 1 hour. NFPA 70, National Electrical Code, Article 450-21 (b).

Findings Include;

While inspecting electrical equipment rooms on March 17-18, 2011, the surveyor observed several storage rooms/electrical rooms housing transformers without the required fire rated construction.
1. 4th floor electrical room across from public restrooms behind central nurses station was observed housing (2) 90 kVA transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
2. 3rd floor electrical room across from public restrooms behind central nurses station was observed housing (2) 90 kVA transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
3. 2nd floor electrical room across from public restrooms behind central nurses station was observed housing (1) 112 kVA transformers and (1) 75 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
4. 3rd floor electrical room across from public restrooms behind central nurses station was observed housing (2) 90 kVA transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
5. 2nd floor electrical room across from public restrooms behind central nurses station was observed housing (1) 112 kVA transformers and (1) 75 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
6. 1st floor electrical room #15 was observed housing (1) 150 kVA transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
7. 1st floor electrical room #13 was observed housing (1) 90kva transformers and (2) 60 kVA transformers. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)
8. 1st floor electrical room #11 was observed housing (1) 150 kVA transformers, (1) 75 kVA transformer, and (1) 40 kVA transformer. This room was observed not sealed to the deck above. (3 inch gap around front wall and left side wall.)

This deficient practice has the potential of affecting 8 of 10 smoke compartments. The administrator and the maintenance director were notified during the survey and in the exit conference.