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Based on observation, the facility failed to maintain the integrity of the building construction in 1 of 4 smoke compartments. This was evidenced by unsealed penetrations in the facility's ceilings that could result in the spread of fire and smoke. This had the potential of harming patients and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the facility's walls and ceilings were observed.

1. On 2/6/2013, at 4:07 p.m., there was a penetration on the ceiling in the Kitchen's Electrical Room. The penetration measured approximately 2-inches diameter and was located around a sprinkler head.

2. On 2/6/2013, at 4:28 p.m., there were three penetrations on the ceiling in the Phone Room, located on the 1st Floor by the elevators. The penetrations surrounded bundles of electrical cables running through the ceiling. The penetrations measured approximately 4-inches by 3-inches, 2-inches by 1-inch, and 3-inches by 1-inch.

Based on observation, the facility failed to maintain the integrity of the corridor doors. This was evidenced by doors that failed to close and positive latch. This affected 3 of 4 smoke compartments and could result in smoke and fire to travel throughout the facility in the event of a fire in the room.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 and with the Life Safety Consultant on 2/7/2013, the corridor doors were observed.

1. On 2/6/2013, at 4:01 p.m., the corridor door to the outpatient day room failed to positive latch.

2. On 2/7/2013, at 8:38 a.m., the corridor door to Room 215 in ASU-II, failed to positive latch.

3. On 2/7/2013, at 8:45 a.m., the corridor door to the group room in ASU-II, was held open by a chair.

4. On 2/7/2013, at 8:52 a.m., the corridor door to Room 314 in ASU-I, failed to positive latch.

5. On 2/7/2013, at 8:54 a.m., the corridor door to Room 307 in ASU-I, failed to positive latch.

6. On 2/7/2013, at 8:52 a.m., the corridor door to the small group room in ASU-I, was held open by a step bench.

7. On 2/7/2013, at 8:57 a.m., the corridor door to the large group room in ASU-I, was held open by a towel.

8. On 2/7/2013, at 9:15 a.m., the corridor door to the clean linen room, located on the 2nd Floor by the elevators, failed to positive latch.

9. On 2/7/2013, at 9:26 a.m., the corridor door to Room 411, located on the 2nd Floor in the Adolescent Unit, failed to positive latch.

10. On 2/7/2013, at 9:27 a.m., the corridor door to Room 407, located on the 2nd Floor in the Adolescent Unit, failed to positive latch.

Based on observation and record review, the facility failed to properly maintain the fire doors. This was evidenced by rolling fire doors containing fusible links that were not tested annually and a fire door with a self-closing device that failed to latch. This affected 1 of 4 smoke compartments and could result in smoke and fire to travel into the exit egress pathway in the event of a fire in the rooms.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.
15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the rolling fire doors were observed and annual inspection records were requested.

1. On 2/6/2013, at 2:34 p.m., the rolling fire doors located in the kitchen and in the front lobby reception area had last been inspected on 10/4/2011. The Director of Plant Operations stated that the rolling fire doors had not been inspected within the past 12 months.

2. On 2/6/2013, at 4:16 p.m., the fire door to the cafeteria contained a self-closing mechanism. The door failed to positive latch when it was held open to the fullest extent then released.

Based on observation, the facility failed to maintain visible exit signs. This was evidenced by exit signs installed that did not illuminate. This could potentially delay evacuation in the event of a power outage and an emergency evacuation. This affected 1 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the exit signs were observed.

On 2/7/2013, at 9:22 a.m., the exit sign installed above the exit door in the stairwell landing, located on the 1st Floor in East portion of the building, failed to illuminate.

Based on observation and record review, the facility failed to ensure that the fire alarm system was properly maintained. This was evidenced by smoke detectors that were not tested during inspections, an initiating device that did not immediately alarm throughout the building after activation, and by the fire alarm not heard throughout the entire building. This had the potential for occupants to not be alerted of a fire, resulting in harm to patients, visitors and staff. This affected 3 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.2.2 Actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 20 seconds after the activation of an initiating device.
Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.
7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
Table 7-3.2 Testing Frequencies
15. Initiating Devices. h. All Smoke Detectors - Functional Annually

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the fire alarm system was tested and documents for the system were reviewed.

1. On 2/6/2013, at 12:20 p.m., the facility's fire alarm system quarterly inspection reports were reviewed. The reports were dated 12/3/12, 9/6/12, 6/5/12, and 3/14/12. The reports identified the following devices as not tested:
- The smoke detector device #30068 in ASU -2 Senior Quiet Room.
- The smoke detector device #0049 in Adolescent Exam Room.
- The smoke detector device #0043 in Outpatient Day Room.
- The smoke detector device #0048 in Outpatient Doc Office.
- The smoke detector device #0029 in Outpatient Staff Office.

2. On 2/6/2013, at 3:18 p.m., the key-operated fire alarm station was activated on the 2nd Floor by Room 416 and the alarm notification did not activate throughout the building within 10 seconds.

3. On 2/6/2013, at 3:22 p.m., the inspector's test valve was activated in the equipment room located on the 2nd Floor. The fire alarm could not be heard in the equipment room when the alarms sounded throughout the building. The room was greater than 140 square feet and was used as storage space. No audible and no visual fire alarm devices where observed in the room.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by the sprinkler system shutoff valve not reporting to the fire control panel when the wheel was turned from its normal position and a damaged sprinkler head. This had the potential to have tampering of the sprinkler system and could result in the sprinkler head not activating during a fire, increasing the risk of injury to patients, visitors and staff. This affected 4 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
3-3.3 Alarm Devices. Where provided, waterflow alarm and supervisory devices shall be tested on a quarterly basis.
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the fire sprinkler system was tested and documents were reviewed.

1. On 2/6/2013, at 3:33 p.m., the Outside Screw and Yoke (OS&Y) hand wheel was turned to attempt to activate the tamper switch. More than two revolutions where turned on the hand wheel and the valve stem moved greater than one-fifth the distance from its normal position with no signal received at the fire control panel.

2. On 2/6/2013, at 4:21 p.m., the sprinkler head installed underneath the air return system in the mechanical room located on the 1st Floor was observed to have a bent deflector.

Based on observation, the facility failed to maintain smoking areas. This was evidenced by no posting of a no smoking sign or symbol by a flammable liquid storage area and by failing to provide ashtrays of safe design and metal containers with self-closing cover devices in areas where smoking is permitted. This deficient practice affected staff and residents and could increase the risk for fire.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, designated smoking areas and flammable liquid storage areas were observed.

1. On 2/6/2013, at 3:49 p.m., the diesel fuel storage area, located outside by the generator, had no posting of a no smoking sign or symbol that was visible from the entrance into the area. The Director of Plant Operations stated that the sign was there but had been faded by the sun.

2. On 2/6/2013, at 3:54 p.m., the smoking area located by the tennis courts on the North portion of the building lacked approved ash trays and/or metal collection containers with self-closing covers into which ashtrays can be emptied into. There was a table top ashtray with no self-closure and a collection can with no self-closure. A resident smoker was observed smoking in the area.

Based on observation, the facility failed to properly store their medical gas cylinders. This was evidenced by an oxygen cylinder that was not individually secured. This affected 1 of 4 smoke compartments. This could cause harm to patients, visitors, and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.1. Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the storage area of medical gas cylinders were observed.

On 2/6/2013, at 4:26 p.m., the medical gas cylinder storage room, located in the clean utility room on the 1st Floor by the elevators, had an oxygen gas cylinder that was standing upright and not individually secured. The cylinder measured approximately 24 cubic feet.

Based on observation, the facility failed to properly maintain duct penetrations. This was evidenced by penetrations through fire/smoke barriers walls that were sealed with non-rated fire material. This affected 3 of 4 smoke compartments and had the potential to allow the spread of fire, resulting in injury to patients, visitors and staff.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the fire/smoke barriers were observed.

1. On 2/7/2013, at 9:57 a.m., the fire wall separating the smoke compartments, located by the Plant Operations Office, was observed to have six penetrations around conduits that were sealed with a white colored material. The wall was observed above the ceiling tiles directly above the cross corridor doors. The Director of Plant Operations confirmed that the wall is constructed with two layers of 5/8-inch gypsum boards and he did not have information that showed that the material used to fill the penetrations was a fire rated type sealant.

2. On 2/7/2013, at 10:03 a.m., the fire wall separating the smoke compartments, located by the elevators on the 1st Floor, was observed to have four penetrations around conduits that were sealed with a foam type material. The wall was observed above the ceiling tiles directly above the cross corridor doors. The Director of Plant Operations confirmed that the wall is constructed with two layers of 5/8-inch gypsum boards and he did not have information that showed that the material used to fill the penetrations was a fire rated type sealant.

Based on observation, the facility failed to maintain the integrity of the building construction in 1 of 4 smoke compartments. This was evidenced by unsealed penetrations in the facility's ceilings that could result in the spread of fire and smoke. This had the potential of harming patients and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the facility's walls and ceilings were observed.

1. On 2/6/2013, at 4:07 p.m., there was a penetration on the ceiling in the Kitchen's Electrical Room. The penetration measured approximately 2-inches diameter and was located around a sprinkler head.

2. On 2/6/2013, at 4:28 p.m., there were three penetrations on the ceiling in the Phone Room, located on the 1st Floor by the elevators. The penetrations surrounded bundles of electrical cables running through the ceiling. The penetrations measured approximately 4-inches by 3-inches, 2-inches by 1-inch, and 3-inches by 1-inch.

Based on observation, the facility failed to maintain the integrity of the corridor doors. This was evidenced by doors that failed to close and positive latch. This affected 3 of 4 smoke compartments and could result in smoke and fire to travel throughout the facility in the event of a fire in the room.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 and with the Life Safety Consultant on 2/7/2013, the corridor doors were observed.

1. On 2/6/2013, at 4:01 p.m., the corridor door to the outpatient day room failed to positive latch.

2. On 2/7/2013, at 8:38 a.m., the corridor door to Room 215 in ASU-II, failed to positive latch.

3. On 2/7/2013, at 8:45 a.m., the corridor door to the group room in ASU-II, was held open by a chair.

4. On 2/7/2013, at 8:52 a.m., the corridor door to Room 314 in ASU-I, failed to positive latch.

5. On 2/7/2013, at 8:54 a.m., the corridor door to Room 307 in ASU-I, failed to positive latch.

6. On 2/7/2013, at 8:52 a.m., the corridor door to the small group room in ASU-I, was held open by a step bench.

7. On 2/7/2013, at 8:57 a.m., the corridor door to the large group room in ASU-I, was held open by a towel.

8. On 2/7/2013, at 9:15 a.m., the corridor door to the clean linen room, located on the 2nd Floor by the elevators, failed to positive latch.

9. On 2/7/2013, at 9:26 a.m., the corridor door to Room 411, located on the 2nd Floor in the Adolescent Unit, failed to positive latch.

10. On 2/7/2013, at 9:27 a.m., the corridor door to Room 407, located on the 2nd Floor in the Adolescent Unit, failed to positive latch.

Based on observation and record review, the facility failed to properly maintain the fire doors. This was evidenced by rolling fire doors containing fusible links that were not tested annually and a fire door with a self-closing device that failed to latch. This affected 1 of 4 smoke compartments and could result in smoke and fire to travel into the exit egress pathway in the event of a fire in the rooms.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.
15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the rolling fire doors were observed and annual inspection records were requested.

1. On 2/6/2013, at 2:34 p.m., the rolling fire doors located in the kitchen and in the front lobby reception area had last been inspected on 10/4/2011. The Director of Plant Operations stated that the rolling fire doors had not been inspected within the past 12 months.

2. On 2/6/2013, at 4:16 p.m., the fire door to the cafeteria contained a self-closing mechanism. The door failed to positive latch when it was held open to the fullest extent then released.

Based on observation, the facility failed to maintain visible exit signs. This was evidenced by exit signs installed that did not illuminate. This could potentially delay evacuation in the event of a power outage and an emergency evacuation. This affected 1 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the exit signs were observed.

On 2/7/2013, at 9:22 a.m., the exit sign installed above the exit door in the stairwell landing, located on the 1st Floor in East portion of the building, failed to illuminate.

Based on observation and record review, the facility failed to ensure that the fire alarm system was properly maintained. This was evidenced by smoke detectors that were not tested during inspections, an initiating device that did not immediately alarm throughout the building after activation, and by the fire alarm not heard throughout the entire building. This had the potential for occupants to not be alerted of a fire, resulting in harm to patients, visitors and staff. This affected 3 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.2.2 Actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 20 seconds after the activation of an initiating device.
Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.
7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
Table 7-3.2 Testing Frequencies
15. Initiating Devices. h. All Smoke Detectors - Functional Annually

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the fire alarm system was tested and documents for the system were reviewed.

1. On 2/6/2013, at 12:20 p.m., the facility's fire alarm system quarterly inspection reports were reviewed. The reports were dated 12/3/12, 9/6/12, 6/5/12, and 3/14/12. The reports identified the following devices as not tested:
- The smoke detector device #30068 in ASU -2 Senior Quiet Room.
- The smoke detector device #0049 in Adolescent Exam Room.
- The smoke detector device #0043 in Outpatient Day Room.
- The smoke detector device #0048 in Outpatient Doc Office.
- The smoke detector device #0029 in Outpatient Staff Office.

2. On 2/6/2013, at 3:18 p.m., the key-operated fire alarm station was activated on the 2nd Floor by Room 416 and the alarm notification did not activate throughout the building within 10 seconds.

3. On 2/6/2013, at 3:22 p.m., the inspector's test valve was activated in the equipment room located on the 2nd Floor. The fire alarm could not be heard in the equipment room when the alarms sounded throughout the building. The room was greater than 140 square feet and was used as storage space. No audible and no visual fire alarm devices where observed in the room.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by the sprinkler system shutoff valve not reporting to the fire control panel when the wheel was turned from its normal position and a damaged sprinkler head. This had the potential to have tampering of the sprinkler system and could result in the sprinkler head not activating during a fire, increasing the risk of injury to patients, visitors and staff. This affected 4 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
3-3.3 Alarm Devices. Where provided, waterflow alarm and supervisory devices shall be tested on a quarterly basis.
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the fire sprinkler system was tested and documents were reviewed.

1. On 2/6/2013, at 3:33 p.m., the Outside Screw and Yoke (OS&Y) hand wheel was turned to attempt to activate the tamper switch. More than two revolutions where turned on the hand wheel and the valve stem moved greater than one-fifth the distance from its normal position with no signal received at the fire control panel.

2. On 2/6/2013, at 4:21 p.m., the sprinkler head installed underneath the air return system in the mechanical room located on the 1st Floor was observed to have a bent deflector.

Based on observation, the facility failed to maintain smoking areas. This was evidenced by no posting of a no smoking sign or symbol by a flammable liquid storage area and by failing to provide ashtrays of safe design and metal containers with self-closing cover devices in areas where smoking is permitted. This deficient practice affected staff and residents and could increase the risk for fire.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, designated smoking areas and flammable liquid storage areas were observed.

1. On 2/6/2013, at 3:49 p.m., the diesel fuel storage area, located outside by the generator, had no posting of a no smoking sign or symbol that was visible from the entrance into the area. The Director of Plant Operations stated that the sign was there but had been faded by the sun.

2. On 2/6/2013, at 3:54 p.m., the smoking area located by the tennis courts on the North portion of the building lacked approved ash trays and/or metal collection containers with self-closing covers into which ashtrays can be emptied into. There was a table top ashtray with no self-closure and a collection can with no self-closure. A resident smoker was observed smoking in the area.

Based on observation, the facility failed to properly store their medical gas cylinders. This was evidenced by an oxygen cylinder that was not individually secured. This affected 1 of 4 smoke compartments. This could cause harm to patients, visitors, and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.1. Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the storage area of medical gas cylinders were observed.

On 2/6/2013, at 4:26 p.m., the medical gas cylinder storage room, located in the clean utility room on the 1st Floor by the elevators, had an oxygen gas cylinder that was standing upright and not individually secured. The cylinder measured approximately 24 cubic feet.

Based on observation, the facility failed to properly maintain duct penetrations. This was evidenced by penetrations through fire/smoke barriers walls that were sealed with non-rated fire material. This affected 3 of 4 smoke compartments and had the potential to allow the spread of fire, resulting in injury to patients, visitors and staff.

Findings:

During a tour of the facility with the Director of Plant Operations on 2/6/2013 through 2/7/2013, the fire/smoke barriers were observed.

1. On 2/7/2013, at 9:57 a.m., the fire wall separating the smoke compartments, located by the Plant Operations Office, was observed to have six penetrations around conduits that were sealed with a white colored material. The wall was observed above the ceiling tiles directly above the cross corridor doors. The Director of Plant Operations confirmed that the wall is constructed with two layers of 5/8-inch gypsum boards and he did not have information that showed that the material used to fill the penetrations was a fire rated type sealant.

2. On 2/7/2013, at 10:03 a.m., the fire wall separating the smoke compartments, located by the elevators on the 1st Floor, was observed to have four penetrations around conduits that were sealed with a foam type material. The wall was observed above the ceiling tiles directly above the cross corridor doors. The Director of Plant Operations confirmed that the wall is constructed with two layers of 5/8-inch gypsum boards and he did not have information that showed that the material used to fill the penetrations was a fire rated type sealant.