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19.1.1.4.1, NFPA 101, LIFE SAFETY CODE
Additions: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

19.1.1.4.2, NFPA 101, LIFE SAFETY CODE
Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
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.

Based on record review, interview, and observation the facility failed to ensure that penetrations to occupancy separation barriers are properly protected.

Findings include:

Record review of the life safety code plans for smoke and fire barriers during tour between 12/1/10 and 12/2/10 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the location of smoke barriers, fire barriers, and occupancy separation barriers throughout the facility.

Interview during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E revealed that occupancy separation barriers consist of 2 hour fire-rated construction and confirmed the locations of occupancy separation barriers.

Observation during tour between 12/1/10 at approximately 10:00 a.m. and 12/2/10 at approximately 9:15 a.m. with Staff A, Staff B, Staff C, Staff D, and Staff E revealed that the following unprotected penetrations are present in the occupancy separations:

1. Lower level, Pain Clinic, SG804

2. Lower level, Business Office, G068

3. First level, Medical Oncology, near C1020

4. Second level, connector 2400

Interview during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E confirmed the location and findings at the time of discovery.

8.2.3.1.1, NFPA 101, LIFE SAFETY CODE
Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials.

4.6.12.1, NFPA 101, LIFE SAFETY CODEWhenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that fire-resistant materials used are provided through out.

Observation during tour on 12/1/10 at approximately 10:40 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed that a portion of the steel I beam used in the area of the occupancy separation barrier located above the suspended ceiling on the lower level at the food service serving area and at the dining area of the business occupancy has its sprayed-on fire-resistant protective coating removed.

Interview during tour on 12/1/10 with Staff A, Staff B, Staff C, Staff D, and Staff E confirmed that the steel above the suspended ceiling in this portion of the building is structural and that the missing sprayed-on fire-resistant protective coating on the steel on both sides of the occupancy separation barrier.

Observation during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E revealed that structural steel has a sprayed-on fire resistant coating applied to its surfaces throughout.

19.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.2, NFPA 101, LIFE SAFETY CODE
Continuity: Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

4.6.12.4, NFPA 101, LIFE SAFETY CODE
Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that smoke barriers are continuous.

Findings include:

Record review of the life safety code plans for smoke and fire barriers during tour between 12/1/10 and 12/2/10 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the location of smoke barriers, fire barriers, and occupancy separation barriers throughout the facility.

Interview during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E confirmed the locations of smoke barriers.

Observation during tour on 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E revealed that a section of the smoke barrier wall above the suspended ceiling in the area of S467 in the Mental Health Services wing on the fourth level is missing a section of sheet-rock approximately the length of the room which is used as a portion of the smoke barrier.

Interview during tour on 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E at the time of discovery revealed that the staff were unaware of the missing section of sheet rock.

19.3.4.1, NFPA 101, LIFE SAFETY CODE
General: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4, NFPA 101, LIFE SAFETY CODE
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

4-3.5.2, NFPA 72, NATIONAL FIRE ALARM CODE
If combination audible/visible appliances are installed, the location of the installed appliance shall be determined by the requirements of 4-4.4.

4-4.3.1, NFPA 72, NATIONAL FIRE ALARM CODE
Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer ' s orientation.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature, is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that visible fire alarm notification devices are free from obstructions.

Findings include:

Observation during tour on 12/1/10 at approximately 2:15 p.m. with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed that the audio-visual fire alarm notification device installed in one of the walls in the Microbiology Lab is obstructed by a specimen refrigerator.

Interview during tour on 12/1/10 with Staff A, Staff B, Staff C, Staff D, and Staff E at the time of discovery confirmed that the audio-visual notification device for the fire alarm system in the Microbiology Lab is obstructed

19.3.5.1, NFPA 101, LIFE SAFETY CODE
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Based on observation and interview during tour the facility failed to ensure that all areas of the building are protected by an automatic, supervised sprinkler system.

Findings include:

Observation during tour on 12/2/10 at approximately 1:30 p.m. with Staff A (V.P. Support Services) revealed that the skylight in the receptionist area of the Administration wing, which is approximately 6 feet, 1 inch in length and width and approximately 5 feet, 1 inch in height is not protected by an automatic, supervised sprinkler system.

Interview during tour on 12/2/10 at the time of discovery with Staff A confirmed that sprinkler protection in the skylight is not present.

19.3.5.1, NFPA 101, LIFE SAFETY CODE
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5, NFPA 101, LIFE SAFETY CODE
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.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-6.5.1.2 Sprinklers shall be arranged to comply with... Table 5-6.5.1.2
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP):

Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft to less than 2 ft 6 in.

Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 5-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft 6 in. to less than 3 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 7-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft to less than 3 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 9-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft 6 in. to less than 4 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 12

Distance from Sprinklers to Side of Obstruction: 4 ft to less than 4 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 14

Distance from Sprinklers to Side of Obstruction: 4 ft 6 in. to less than 5 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 16-1/2

Distance from Sprinklers to Side of Obstruction: 5 ft and greater
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 18

2-2.1.1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
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.

3-2.5.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The liquid in bulb-type sprinklers shall be color coded in accordance with Table 3-2.5.1.
Table 3-2.5.1 Temperature Ratings, Classifications, and Color Codings:

Ordinary Temperature Classification
Glass Bulb Colors: Orange or red
Maximum Ceiling Temperature: 100
Temperature Rating: 135-170

Intermediate Temperature Classification
Glass Bulb Colors: Yellow or green
Maximum Ceiling Temperature: 150
Temperature Rating: 175-225

High Temperature Classification
Glass Bulb Colors: Blue
Maximum Ceiling Temperature: 225
Temperature Rating: 250-300

Extra High Temperature Classification
Glass Bulb Colors: Purple
Maximum Ceiling Temperature: 300
Temperature Rating: 325-375

5-3.1.4.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Ordinary-temperature-rated sprinklers shall be used throughout buildings.
Exception No. 1: Where maximum ceiling temperatures exceed 100F (38C), sprinklers with temperature ratings in accordance with the maximum ceiling temperatures of Table 3-2.5.1 shall be used.
Exception No. 2: Intermediate- and high-temperature sprinklers shall be permitted to be used throughout ordinary and extra hazard occupancies.
Exception No. 3: Sprinklers of intermediate- and high-temperature classifications shall be installed in specific locations as required by 5-3.1.4.2.

5-3.1.4.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout...
(1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification.
(2) Sprinklers located within 12 in. (305 mm) to one side or 30 in. (762 mm) above an uncovered steam main, heating coil, or radiator shall be of the intermediate-temperature classification.
(3) Sprinklers within 7 ft (2.1 m) of a low-pressure blowoff valve that discharges free in a large room shall be of the high-temperature classification.
(4) Sprinklers under glass or plastic skylights exposed to the direct rays of the sun shall be of the intermediate-temperature classification.
(5) Sprinklers in an unventilated, concealed space, under an uninsulated roof, or in an unventilated attic shall be of the intermediate-temperature classification.
(6) Sprinklers in unventilated show windows having high-powered electric lights near the ceiling shall be of the intermediate-temperature classification.
(7) Sprinklers protecting commercial-type cooking equipment and ventilation systems shall be of the high- or extra-high-temperature classification as determined by use of a temperature-measuring device.

Based on observation and interview the facility failed to ensure that automatic, supervised sprinkler systems are properly maintained.

Findings include:

Observation during tour between 12/1/10 at 11:15 a.m. and 12/2/10 at 11:15 a.m. with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the following:

1. Obstructed spray pattern of at least one sprinkler head in NG211 in North Radiology due to the proximity of ceiling mounted railings to the sprinkler head. The deflector of the sprinkler head projects approximately 1-1/2 inches from the ceiling, due to ceiling mounted railings which project approximately 4 inches from the ceiling and that is approximately 11 inches from the sprinkler head.

2. Improperly rated sprinkler heads installed in the following locations:
a. Stair E, level 1 with at least one intermediate temperature rated head installed.
b. Room S544 (Soiled Utility Room) with at least one intermediate temperature rated head installed.
c. Room S572 (ES Closet) with at least one intermediate temperature rated head installed.
d. Room S502 (Equipment Room 2) with at least one intermediate temperature rated head installed.

Interview during tour on 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E at the time of discovery confirmed that no heat sources are present to require intermediate temperature rated sprinkler heads installed and confirmed the findings.

8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

1-11.4, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Clearance. Clearances under the bottoms of doors shall be in accordance with Table 1-11.4.
Table 1-11.4 Clearances Under the Bottoms of Doors
Clearance Between Bottom of door and raised noncombustible sills: 3/8 Inch
Clearance Between Floor where no sill exists: 3/4 Inch
Clearance Between Floor coverings: 1/2 Inch

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
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.

Based on record review, interview, and observation the facility failed to ensure that fire barriers and fire barrier doors are properly maintained.

Findings include:

Record review of the life safety code plans for smoke and fire barriers during tour between 12/1/10 and 12/2/10 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the location of smoke barriers, fire barriers, and occupancy separation barriers throughout the facility.

Interview during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E confirmed the locations of fire barriers.

Observation during tour on 12/1/10 between 11:00 a.m. and 1:00 p.m. with Staff A, Staff B, Staff C, Staff D, and Staff E revealed the following:

1. The fire barrier wall that has door number NG318 has unprotected penetrations in the area of where the HVAC (Heating, Ventilation, and Air Conditioning) duct is installed through the fire barrier.

2. The double leaf fire door assembly located in the central building at the fire barrier assembly on level 2A has approximately 1 inch of space between the base of a door leaf and the floor in areas.

Interview during tour on 12/1/10 with Staff A, Staff B, Staff C, Staff D, and Staff E at the times of discovery confirmed the findings.

19.5.1, NFPA 101, LIFE SAFETY CODE
Utilities: Utilities shall comply with the provisions of Section 9.1.

9.1.2, NFPA 101, LIFE SAFETY CODE
Electric: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

110-12, NFPA 70, NATIONAL ELECTRICAL CODE
(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

Based on observation and interview the facility failed to ensure that electrical installations are properly enclosed.

Findings include:

Observation during tour between 12/1/10 and 12/2/10 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the following:

One electrical distribution panel in room S1115B and electrical distribution panels EPLSGFA and EHLSG1 have open areas where breakers and/or protective blanks are missing.

Interview during tour on 12/1/10 and 12/2/10 with with Staff A, Staff B, Staff C, Staff D, and Staff E at the time of discovery confirmed the findings.

19.1.1.4.1, NFPA 101, LIFE SAFETY CODE
Additions: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

19.1.1.4.2, NFPA 101, LIFE SAFETY CODE
Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
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.

Based on record review, interview, and observation the facility failed to ensure that penetrations to occupancy separation barriers are properly protected.

Findings include:

Record review of the life safety code plans for smoke and fire barriers during tour between 12/1/10 and 12/2/10 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the location of smoke barriers, fire barriers, and occupancy separation barriers throughout the facility.

Interview during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E revealed that occupancy separation barriers consist of 2 hour fire-rated construction and confirmed the locations of occupancy separation barriers.

Observation during tour between 12/1/10 at approximately 10:00 a.m. and 12/2/10 at approximately 9:15 a.m. with Staff A, Staff B, Staff C, Staff D, and Staff E revealed that the following unprotected penetrations are present in the occupancy separations:

1. Lower level, Pain Clinic, SG804

2. Lower level, Business Office, G068

3. First level, Medical Oncology, near C1020

4. Second level, connector 2400

Interview during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E confirmed the location and findings at the time of discovery.

8.2.3.1.1, NFPA 101, LIFE SAFETY CODE
Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials.

4.6.12.1, NFPA 101, LIFE SAFETY CODEWhenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that fire-resistant materials used are provided through out.

Observation during tour on 12/1/10 at approximately 10:40 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed that a portion of the steel I beam used in the area of the occupancy separation barrier located above the suspended ceiling on the lower level at the food service serving area and at the dining area of the business occupancy has its sprayed-on fire-resistant protective coating removed.

Interview during tour on 12/1/10 with Staff A, Staff B, Staff C, Staff D, and Staff E confirmed that the steel above the suspended ceiling in this portion of the building is structural and that the missing sprayed-on fire-resistant protective coating on the steel on both sides of the occupancy separation barrier.

Observation during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E revealed that structural steel has a sprayed-on fire resistant coating applied to its surfaces throughout.

19.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.2, NFPA 101, LIFE SAFETY CODE
Continuity: Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

4.6.12.4, NFPA 101, LIFE SAFETY CODE
Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that smoke barriers are continuous.

Findings include:

Record review of the life safety code plans for smoke and fire barriers during tour between 12/1/10 and 12/2/10 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the location of smoke barriers, fire barriers, and occupancy separation barriers throughout the facility.

Interview during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E confirmed the locations of smoke barriers.

Observation during tour on 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E revealed that a section of the smoke barrier wall above the suspended ceiling in the area of S467 in the Mental Health Services wing on the fourth level is missing a section of sheet-rock approximately the length of the room which is used as a portion of the smoke barrier.

Interview during tour on 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E at the time of discovery revealed that the staff were unaware of the missing section of sheet rock.

19.3.4.1, NFPA 101, LIFE SAFETY CODE
General: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4, NFPA 101, LIFE SAFETY CODE
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

4-3.5.2, NFPA 72, NATIONAL FIRE ALARM CODE
If combination audible/visible appliances are installed, the location of the installed appliance shall be determined by the requirements of 4-4.4.

4-4.3.1, NFPA 72, NATIONAL FIRE ALARM CODE
Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer ' s orientation.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature, is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that visible fire alarm notification devices are free from obstructions.

Findings include:

Observation during tour on 12/1/10 at approximately 2:15 p.m. with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed that the audio-visual fire alarm notification device installed in one of the walls in the Microbiology Lab is obstructed by a specimen refrigerator.

Interview during tour on 12/1/10 with Staff A, Staff B, Staff C, Staff D, and Staff E at the time of discovery confirmed that the audio-visual notification device for the fire alarm system in the Microbiology Lab is obstructed

19.3.5.1, NFPA 101, LIFE SAFETY CODE
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Based on observation and interview during tour the facility failed to ensure that all areas of the building are protected by an automatic, supervised sprinkler system.

Findings include:

Observation during tour on 12/2/10 at approximately 1:30 p.m. with Staff A (V.P. Support Services) revealed that the skylight in the receptionist area of the Administration wing, which is approximately 6 feet, 1 inch in length and width and approximately 5 feet, 1 inch in height is not protected by an automatic, supervised sprinkler system.

Interview during tour on 12/2/10 at the time of discovery with Staff A confirmed that sprinkler protection in the skylight is not present.

19.3.5.1, NFPA 101, LIFE SAFETY CODE
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5, NFPA 101, LIFE SAFETY CODE
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.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-6.5.1.2 Sprinklers shall be arranged to comply with... Table 5-6.5.1.2
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP):

Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft to less than 2 ft 6 in.

Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 5-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft 6 in. to less than 3 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 7-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft to less than 3 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 9-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft 6 in. to less than 4 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 12

Distance from Sprinklers to Side of Obstruction: 4 ft to less than 4 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 14

Distance from Sprinklers to Side of Obstruction: 4 ft 6 in. to less than 5 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 16-1/2

Distance from Sprinklers to Side of Obstruction: 5 ft and greater
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 18

2-2.1.1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
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.

3-2.5.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The liquid in bulb-type sprinklers shall be color coded in accordance with Table 3-2.5.1.
Table 3-2.5.1 Temperature Ratings, Classifications, and Color Codings:

Ordinary Temperature Classification
Glass Bulb Colors: Orange or red
Maximum Ceiling Temperature: 100
Temperature Rating: 135-170

Intermediate Temperature Classification
Glass Bulb Colors: Yellow or green
Maximum Ceiling Temperature: 150
Temperature Rating: 175-225

High Temperature Classification
Glass Bulb Colors: Blue
Maximum Ceiling Temperature: 225
Temperature Rating: 250-300

Extra High Temperature Classification
Glass Bulb Colors: Purple
Maximum Ceiling Temperature: 300
Temperature Rating: 325-375

5-3.1.4.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Ordinary-temperature-rated sprinklers shall be used throughout buildings.
Exception No. 1: Where maximum ceiling temperatures exceed 100F (38C), sprinklers with temperature ratings in accordance with the maximum ceiling temperatures of Table 3-2.5.1 shall be used.
Exception No. 2: Intermediate- and high-temperature sprinklers shall be permitted to be used throughout ordinary and extra hazard occupancies.
Exception No. 3: Sprinklers of intermediate- and high-temperature classifications shall be installed in specific locations as required by 5-3.1.4.2.

5-3.1.4.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout...
(1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification.
(2) Sprinklers located within 12 in. (305 mm) to one side or 30 in. (762 mm) above an uncovered steam main, heating coil, or radiator shall be of the intermediate-temperature classification.
(3) Sprinklers within 7 ft (2.1 m) of a low-pressure blowoff valve that discharges free in a large room shall be of the high-temperature classification.
(4) Sprinklers under glass or plastic skylights exposed to the direct rays of the sun shall be of the intermediate-temperature classification.
(5) Sprinklers in an unventilated, concealed space, under an uninsulated roof, or in an unventilated attic shall be of the intermediate-temperature classification.
(6) Sprinklers in unventilated show windows having high-powered electric lights near the ceiling shall be of the intermediate-temperature classification.
(7) Sprinklers protecting commercial-type cooking equipment and ventilation systems shall be of the high- or extra-high-temperature classification as determined by use of a temperature-measuring device.

Based on observation and interview the facility failed to ensure that automatic, supervised sprinkler systems are properly maintained.

Findings include:

Observation during tour between 12/1/10 at 11:15 a.m. and 12/2/10 at 11:15 a.m. with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the following:

1. Obstructed spray pattern of at least one sprinkler head in NG211 in North Radiology due to the proximity of ceiling mounted railings to the sprinkler head. The deflector of the sprinkler head projects approximately 1-1/2 inches from the ceiling, due to ceiling mounted railings which project approximately 4 inches from the ceiling and that is approximately 11 inches from the sprinkler head.

2. Improperly rated sprinkler heads installed in the following locations:
a. Stair E, level 1 with at least one intermediate temperature rated head installed.
b. Room S544 (Soiled Utility Room) with at least one intermediate temperature rated head installed.
c. Room S572 (ES Closet) with at least one intermediate temperature rated head installed.
d. Room S502 (Equipment Room 2) with at least one intermediate temperature rated head installed.

Interview during tour on 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E at the time of discovery confirmed that no heat sources are present to require intermediate temperature rated sprinkler heads installed and confirmed the findings.

8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

1-11.4, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Clearance. Clearances under the bottoms of doors shall be in accordance with Table 1-11.4.
Table 1-11.4 Clearances Under the Bottoms of Doors
Clearance Between Bottom of door and raised noncombustible sills: 3/8 Inch
Clearance Between Floor where no sill exists: 3/4 Inch
Clearance Between Floor coverings: 1/2 Inch

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
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.

Based on record review, interview, and observation the facility failed to ensure that fire barriers and fire barrier doors are properly maintained.

Findings include:

Record review of the life safety code plans for smoke and fire barriers during tour between 12/1/10 and 12/2/10 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the location of smoke barriers, fire barriers, and occupancy separation barriers throughout the facility.

Interview during tour between 12/1/10 and 12/2/10 with Staff A, Staff B, Staff C, Staff D, and Staff E confirmed the locations of fire barriers.

Observation during tour on 12/1/10 between 11:00 a.m. and 1:00 p.m. with Staff A, Staff B, Staff C, Staff D, and Staff E revealed the following:

1. The fire barrier wall that has door number NG318 has unprotected penetrations in the area of where the HVAC (Heating, Ventilation, and Air Conditioning) duct is installed through the fire barrier.

2. The double leaf fire door assembly located in the central building at the fire barrier assembly on level 2A has approximately 1 inch of space between the base of a door leaf and the floor in areas.

Interview during tour on 12/1/10 with Staff A, Staff B, Staff C, Staff D, and Staff E at the times of discovery confirmed the findings.

19.5.1, NFPA 101, LIFE SAFETY CODE
Utilities: Utilities shall comply with the provisions of Section 9.1.

9.1.2, NFPA 101, LIFE SAFETY CODE
Electric: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

110-12, NFPA 70, NATIONAL ELECTRICAL CODE
(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

Based on observation and interview the facility failed to ensure that electrical installations are properly enclosed.

Findings include:

Observation during tour between 12/1/10 and 12/2/10 with Staff A (V.P. Support Services), Staff B (Director, Facilities Maintenance), Staff C (Director, Safety and Security), Staff D (Chief Facilities Coordinator), and Staff E (Chief Facilities Coordinator) revealed the following:

One electrical distribution panel in room S1115B and electrical distribution panels EPLSGFA and EHLSG1 have open areas where breakers and/or protective blanks are missing.

Interview during tour on 12/1/10 and 12/2/10 with with Staff A, Staff B, Staff C, Staff D, and Staff E at the time of discovery confirmed the findings.