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Based on observation and staff interview the facility failed to ensure 2-hour fire barriers were fire resistant in 1 of 3 smoke compartments. The findings were:

1. Observation on 05/05/15 at 8:25 AM revealed the first floor 2-hour fire barrier wall separating Natrona Hall and the Administration Building had two unsealed penetrations greater than 1 inch in diameter. Interview with Facility Security Staff at the time of the observation acknowledged the penetrations.

2. Observation on 05/05/15 at 9:00 AM revealed the basement 2-hour fire barrier door separating Natrona Hall and the Administration Building was blocked open with a door stop. At the time of the observation, the Facility Security Staff acknowledged the fire door was blocked open.

3. Observation on 05/05/15 at 8:50 AM revealed the first floor 2-hour fire barrier wall separating Weston Hall and the Administration Building had two unsealed penetrations greater than 1 inch in diameter. Interview with Facility Security Staff at the time of the observation acknowledged the penetrations.


Ref:
2000 NFPA 101, Section 8.2.3.2.4

Based on observation and staff interview, the facility failed to protect vertical openings with a fire resistance rating of at least one hour. The finding was:

Observation of the Teton/Sweetwater Hall stairwell on 05/05/15 at 10:35 AM revealed the first floor fire door was blocked open with a wood wedge and the basement fire door was blocked open with a sandbag. At the time of the observations, the Facility Security Officer acknowledged the findings.

Ref:
2000 NFPA 101, Section 15.3.1 and 8.2.5.2

Based on observation and staff interview, the facility failed to arrange exit access to that exits are readily accessible at all times. The finding was:

Observation on 05/05/15 at 9:11 AM revealed a electric powered man lift parked in front of the exit, obstructing the path of egress. At the time of the observation, the Facility Security Officer acknowledged the path of egress being block.

Ref:
2000 NFPA 101, Sections 7.2.1.4.5 and 19.2.2.2.5

Based on document review and staff interview, the facility failed to provide documentation identifying certification of the central station fire alarm system in accordance with NFPA 72. The finding was:

Document review of the central station fire alarm system on 05/05/15 at 8:40 AM revealed that UL certificate was not posted on or near the fire alarm system. At the time of the review, the Facility Security Staff acknowledged the certificate was not posted.

Ref:
2000 NFPA 101, Section 39.3.4.1 and 9.6.1.4
1999 NFPA 72, Section 1-6.2.3.1.1

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are continuously maintained per the requirements of NFPA 25. The finding was:

Interview with the Facility Electrician on 05/06/15 at 9:50 AM revealed the domestic wet sprinkler system was not working. The Facility Electrician stated the system had not been operational for some time.

Ref:
2000 NFPA 101 Section 4.6.12.2 and 4.6.12.3
1998 NFPA 25, Section 2-2.1.1

Based on observation and staff interview, the facility failed to provide an adequate medical gas storage area per NFPA 99. The finding was:

Observation of the exterior Oxygen Storage Room on 05/05/15 at 3:20 PM revealed an electric heater installed in the room approximately 18 inches off the floor. At the time of the observation, the Facility Security Officer acknowledge the electric heater located inside the Oxygen Storage Room.

Ref:
2000 NFPA 101, Section 19.3.2.4
1999 NFPA 99, Section 8.3.11.2(i)

Based on observation and staff interview the facility failed to provide cover plates for electrical equipment in 1 of 3 smoke compartments. The finding was:

Observation on 05/05/15 at 9:45 AM revealed the electrical junction box in Storeroom #24 did not have a cover plate. Interview with the Facility Security Staff at the time of the observation revealed that cover plates were not routinely inspected.

Ref:
2000 NFPA 101, Section 9.1.2

Based on document review and staff interview, the facility failed to maintain a policy to address an event where the sprinkler system is out of service for more than 4 hours in a 24-hour period. The finding was:

Document review on 05/06/15 from 1:15 PM to 5:00 PM revealed that a fire watch policy was not available for review. Interview and follow up document review with the Security Manager was not able to establish the existence of a fire watch policy.

Ref:
2000 NFPA 101, Section 9.7.6.1

Based on document review and staff interview, the facility failed to maintain a policy to address an event where the fire alarm is out of service for more than 4 hours in a 24-hour period. The finding was:

Document review on 05/06/15 from 1:15 PM to 5:00 PM revealed that a fire watch policy was not available for review. Interview and follow up document review with the Security Manager was not able to establish the existence of a fire watch policy.

Ref:
2000 NFPA 101, Section 9.6.1.8