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Based on observations and confirmed by staff, the facility failed to assure that corridor walls are constructed as required.

THE FINDINGS INCLUDE:

While touring the facility on 11/2/15 through 11/5/15 it was revealed that the corridor walls are not constructed to resist the passage of smoke in the following areas:

- The electric/data closets, adjacent to #17 S offices. These closets are located on the third floor level through the 12th floor level south corridors. Typically, four electrical metal tubing conduits in addition to CAT 5 data lines penetrate the corridor walls within these closets below the ceiling. Voids between the gypsum wallboard (GWB) and the conduits and wires remain unsealed.

- There are many unsealed wall penetrations throughout the facility, typically where the CAT 5 data wire was installed below the ceiling at offices #17S, # 16S, # 15S and # 01S from the third floor level through the 12th floor level.

- Patient rooms, where the televisions were installed in patient rooms on the third floor through the seventh floor levels.

As a result of the findings the facility is found to be non-compliant with NFPA #101 "Life Safety Code" Chapter 19 Section 19.3.6.2.


The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.3 requires corridor doors other than vertical openings, exits or hazards areas to be 1-3/4" thick, solid-bonded core wood or of construction that resists fire for at least 20 minutes and shall be constructed to resist the passage of smoke. There shall be no impediment to closing the door, only approved hold open devices may be used.

Section 19.3.6.3.6 states Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

THE FINDINGS INCLUDE:

While conducting the facility tour during the morning and afternoon hours of 11/2/15 through 11/5/15, observations revealed the following deficiencies regarding corridor doors.

1. The door to room #11 on the 11 North Unit does not latch as required. The strike plate is out of adjustment preventing the door from achieving positive latching as required.

2. The door to the Intake Coordinator's Office is not equipped with any latching mechanism. As a result, the door in unable to achieve positive latching as required.

3. The Medication Room located on the 10 North Unit is equipped with two Dutch Style doors. The doors do not meet the criteria for a Dutch door as the meeting edges of the upper and lower leaves are neither equipped with an astragal, a rabbet, or a bevel, nor is an automatic latch mechanism provided.

4. The Medication Room located on the 9 North Unit is equipped with two Dutch Style doors. The doors do not meet the criteria for a Dutch door as the meeting edges of the upper and lower leaves are neither equipped with an astragal, a rabbet, or a bevel, nor is an automatic latch mechanism provided.

5. The door to the Relaxation Room on the 9 North Unit does not latch as required as the strike plate is missing. As a result, there is an approximate 1/2" gap between the door and frame when in the closed position. Due to the excessive gap, the door is unable to resist the passage of smoke as required.

6. The door to the Nurse Managers' Office on the 8 North Unit has an approximate 1-1/4" unsealed hole. As a result, the door is unable to resist the passage of smoke as required.

7. The door to room #702 on the 7 North Unit does not latch as required as the strike plate is missing. As a result, there is an approximate 1/2" gap between the door and frame when in the closed position. Due to the excessive gap, the door is unable to resist the passage of smoke as required.

8. The door to room #502 on the 5 North Unit does not latch as required as the strike plate is bent. As a result of the bent striker plate, the door will not close and achieve positive latching.

9. The Human Resources Office located on the 4 North Unit is equipped with a Dutch Style door. The door does not meet the criteria for a Dutch door as the meeting edges of the upper and lower leaves are neither equipped with an astragal, a rabbet, or a bevel, nor is an automatic latch mechanism provided.

10. The door to room #309 on the 3 North Unit does not latch as required as the strike plate is missing. As a result, there is an approximate 1/2" gap between the door and frame when in the closed position. Due to the excessive gap, the door is unable to resist the passage of smoke as required.

As a result of the findings the facility is found to be non-compliant with NFPA #101 "Life Safety Code" Chapter 19 Section 19.3.6.3.

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations, the facility failed to ensure compliance with NFPA 101, Chapter 19. Section 19.3.7.3 which states any required smoke barrier shall be constructed in accordance with Chapter 8. Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour. Section 8.3.2 requires that smoke barriers are constructed to resist the passage of smoke and are continuous to floor/roof slabs above suspended ceilings. Section 8.3.6.1 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers to be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or to be protected by an approved device that is designed for the specific purpose.

THE FINDINGS INCLUDE:

Observations while inspecting the facility's designated smoke barriers during survey between 11/2/15 and 11/5/15 revealed the following:

The smoke barriers located on floors 2 through 12 were each originally designed as a combination smoke barrier/horizontal exit (located between the elevator shaft and stairwell #3). However, the double doors located on each floor level at this location have been modified from the initial construction. The wired glass vision panels in all of the doors have been replaced with a non-rated plexi-glass material.

As a result of the doors being modified to less than a 20-minute fire rating, the required smoke barriers are no longer provided.

In addition, the wall sections above the in-lay ceiling tiles at the cross corridor doors on these floors have unsealed penetrations around data wire conduit and pipe penetrations.

As a result of the findings the facility was found to be non-compliant with Chapter 8 Section 8.3.2 and Chapter 8 Section 8.3.6.1. of NFPA #101 the "Life Safety Code".

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliancy with NFPA regulations governing the protection of hazardous areas. NFPA #101 "Life Safety Code" Chapter 19 Section 19.3.2.1 "Hazardous Areas" states the following:
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Section 19.3.2.1 also requires the doors to rooms or spaces larger than 50 sq. ft. including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction, to be self-closing.

Section 19.3.6.3.6 states Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

THE FINDINGS INCLUDE:

While conducting the facility tour during the morning and afternoon hours of 11/2/15 through 11/5/15, observations revealed the following deficiencies regarding hazardous locations.

1. The kitchen entrance/exit doors separating the kitchen from the exit corridors are equipped with self-closing and self-latching mechanisms as required by code. Doors that are held open to facilitate the operation of food delivery services are equipped with magnetic hold open devices that automatically release upon activation of the fire alarm system.
However, due to the inability of certain communicating openings between the kitchen and main public dining area (doors and food pass through windows) to meet the requirements of Chapter 19 Section 19.3.2.1, the main public dining area is considered an extension of the kitchen's hazardous area and must be protected as such.
Subsequently an examination of the main public dining room exit doors revealed that the door exiting to the corridor identified as Department of Corrections Corridor was missing its latching device and was unable to remain in the closed position as required.

2. The facility's Equipment Washing Room located off the Department of Corrections Corridor is greater than 50 sq ft in size, used for the storage of numerous items considered to be combustible in nature and is not equipped with an operable self-closing mechanism. Observations revealed that the door has an automatic self-closing device mounted to it, however at time of survey it was disconnected and non-functioning.

3. The door to the Soiled Utility Room located on the 10 North Unit is not equipped with a self closing device.

4. The door to the Soiled Utility Room located on the 9 North Unit is not equipped with a self closing device.

5. The door to the Soiled Utility Room located on the 6 North Unit was observed to be non-functional. The retractable latching mechanism was wedged in the retracted position with a piece of cardboard. As a result, the door was not able to achieve positive latching as required.

6. The two doors to the Central Sterile Room are lacking self closing devices. In addition, one of the doors is a non-conforming Dutch style door. The door does not meet the criteria for a Dutch door as the meeting edges of the upper and lower leaves are neither equipped with an astragal, a rabbet, or a bevel, nor is an automatic latch mechanism provided.

7. The two doors to the Medical Records Room are lacking self closing devices. In addition, one of the doors is a non-conforming Dutch style door. The door does not meet the criteria for a Dutch door as the meeting edges of the upper and lower leaves are neither equipped with an astragal, a rabbet, or a bevel, nor is an automatic latch mechanism provided.
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As a result of the findings the facility is found to be non-compliant with NFPA #101 "Life Safety Code" Chapter 19 Section 19.3.2.1.

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that exit egress routes are properly provided. Section 19.2.4.1 states not less than two exits of the types described in 19.2.2.2 through 19.2.2.10, remotely located from each other, shall be provided for each floor or fire section of the building.

Section 19.2.2.3 states stairs complying with 7.2.2 shall be permitted.

Section 7.2.6.1 states exit passageways used as exit components shall conform to the general requirements of Section 7.1 and to the requirements of 7.2.6.

Section 7.2.6.2 states an exit passageway shall be separated from other parts of the building as specified in 7.1.3.2.

Section 7.1.3.2.1 states where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closer's complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.
(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
(f) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures.

Section 7.1.3.2.2 states an exit enclosure shall provide a continuous protected path of travel to an exit discharge.

Section 7.7.1 states exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Section 7.7.2 states not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall be permitted to discharge through areas on the level of exit discharge, provided that the criteria of 7.7.2(1) through (3) are met:
(1) Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit.
(2) The level of discharge shall be protected throughout by an approved, automatic sprinkler system in accordance with Section 9.7, or the portion of the level of discharge used for this purpose shall be protected by an approved, automatic sprinkler system in accordance with Section 9.7 and shall be separated from the non-sprinklered portion of the floor by a fire resistance rating meeting the requirements for the enclosure of exits (see 7.1.3.2.1).
(3) The entire area on the level of discharge shall be separated from areas below by construction having a fire resistance rating not less than that required for the exit enclosure.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 11/2/15 through 11/5/15, it was observed that floors 2 through 12 are not provided with two approved remote means of egress as required.

The facility has a total of 5 stairwells which traverse throughout the entire height of the building. Of the 5 stairwells provided, only stairwell #5 is currently conforming. Stair #5 leads directly to the exterior of the building at the point of discharge from the stairwell.

Stair #2 and stair #3 are both interior stairwells which terminate inside of the building.

Stair #4 and stair #6 which terminate at the ground floor level were originally conforming stairwells. These stairwells lead into exit egress routes that were originally constructed as a 2-hour continuation of the stairwells. However, the approximate 20' of egress corridors in each of these locations has been modified throughout the years. Modifications to both doors and walls in these two locations have reduced the level of protection from 2-hours to 20-minutes.

In addition, floors 2 through 12 were each originally designed with a horizontal exit located between the elevator shaft and stairwell #3. However, the double doors located on each floor level at this location have been modified from the initial construction. The wired glass vision panels in all of the doors have been replaced with a non-rated plexi-glass material.

As a result of the doors being modified to less than a 20-minute fire rating, the required horizontal exits are no longer provided.

NOTE: Stairwell #1 is a communicating stair between the ground and first floor levels only.

As a result of the findings the facility is found to be non-compliant with NFPA 101 "Life Safety Code" Chapter 19 Section 19.2.4.1. as each floor level is not provided with two conforming egress routes.

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations, the facility failed to ensure that exit stairways are enclosed as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 11/2/15 through 11/5/15 revealed that stair door #3 on the first floor level failed to latch in the door frame when released from the open position. In addition, the door has holes through the door where the door closer was moved rendering it not smoke tight.

As a result of the findings the facility is found to be non-compliant with NFPA #101 "Life Safety Code" Chapter 19 Section 19.3.1.2.


The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that the means of egress are in compliance with chapter 7.

Section 7.2.1.5.4 states that a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor.

THE FINDINGS INCLUDE:

While touring the facility on 11/2/15 through 11/5/15, it was observed that stair #5 and stair #2 on the twelfth and fourth floor levels are provided with the latch mechanisms that measure 52" above the floor.

As a result of the findings the facility is found to be non-compliant with NFPA 101 "Life Safety Code" Chapter 7 Section 7.2.1.5.4 as each stair door is not provided conforming latch mechanisms.

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure all egress routes are maintained as required. Section 19.2.2.2.5 states doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

THE FINDINGS INCLUDE:

While conducting the facility tour during the morning and afternoon hours of 11/2/15 through 11/5/15, observations revealed the following deficiencies regarding corridor doors.

1. During the afternoon hours of 11/3/15 while touring the 12 North Unit and the adjoining suite, the suite door was observed to be locked from the corridor side, preventing re-entry into the egress corridor. It was stated by hospital staff that the 12 North Unit is occupied by the Department of Correction (DOC) and access is prohibited. However, the suite is occupied by the DOC and hospital staff, and the second means of egress from the suite is into the DOC corridor. The hospital staff did not have the appropriate key to gain entry to the second means of egress.

2. During the afternoon hours of 11/3/15 while touring the 11 North Unit, the door to the Dining Room was observed to be equipped with a dead bolt style locking mechanism. Although the door could be unlocked from the inside with a thumb latch, a key must be used from the corridor side of the door for unlocking purposes. When staff members were asked to produce the key to this room, it was not readily available. Only one staff member had access to the key which took approximately 3-minutes to locate. During the survey tour, one staff member with approximately 8 patients were observed to be utilizing the room at the time.

As a result of the findings the facility is found to be non-compliant with NFPA 101 "Life Safety Code" Chapter 19 Section 19.2.2.2.5.

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 states artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.

Section 7.8.1.4 states required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

THE FINDINGS INCLUDE:

Observations while touring the facility on 11/5/15 revealed that the light bulb within the ground floor level of stair #5 was not illuminated. The bulb had burned out and the area was in darkness.

As a result of the findings the facility is found to be non-compliant with NFPA 101 "Life Safety Code" Chapter 7 Section 7.8.1.2 as each floor level is not provided with conforming illumination.

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA 72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

THE FINDINGS INCLUDE:

While conducting the facility tour during the morning and afternoon hours of 11/2/15 through 11/5/15, observations revealed the following deficiencies regarding the fire alarm system.

1. The smoke detector located in the T-wing section of the 11 North Unit was observed to be covered with clear packing tape. As a result, the smoke detector is not capable of sensing smoke particles as required.

2. The smoke detector located in the public bathroom of the 6 North Unit was observed to be covered with a rubber glove. As a result, the smoke detector is not capable of sensing smoke particles as required.

3. The smoke detector located in the Electric Closet of the 2nd floor mechanical space was observed to be covered with a rubber glove. As a result, the smoke detector is not capable of sensing smoke particles as required.

As a result of the findings the facility is found to be non-compliant with NFPA 72 (National Fire Alarm Code) section 7-1.2

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations the facility, which is identified as fully sprinklered, failed to ensure compliancy with the following regulations included in the 1999 Edition of NFPA 13 "Standard for the Installation of Sprinkler Systems".

1. NFPA 13 Section 1-6.1 states a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.
Exception: This requirement shall not apply where specific sections of this standard permit the omission of sprinklers.

NFPA 13 Section 5.13.11 states sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible. Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure which includes protection for penetrations. The opening of the enclosure must be protected by a self-closing, 1.5 hour fire rated door as required in NFPA #101 Section 8.2.3.2.3.1 and NFPA #80 Section 8.2.3.2.1(b)
(d) No combustible storage is permitted to be stored in the room.

2. NFPA 13 section 5-6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) for Standard Pendent and Upright Spray Sprinklers.

3. NFPA 25, Section 2.2.1.1 states 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.

NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition. Chapter 5 Section 5.3.1.5.2 states when existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed. NFPA 13 1999 Edition Chapter 5 Section 5-3.1.5.1 states in Exception No. 3 that when individual standard response sprinklers are replaced in existing systems, standard response sprinklers shall be permitted to be used.

NFPA 13, Section 1-4.2 General Definitions
Compartment. A space completely enclosed by walls and a ceiling. The compartment enclosure is permitted to have openings to an adjoining space if the openings have a minimum lintel depth of 8 in. (203 mm) from the ceiling.

THE FINDINGS INCLUDE:

1. While conducting the facility tour on the afternoon of 11/05/15, at approximately 12:45 P.M., it was observed that the non-sprinklered, 2-hour fire rated electrical equipment room (identified as the "Transformer Room") located adjacent to the rear of the pharmacy on the building's ground floor is being used for the storage of various items considered to be combustible in nature. The items include cardboard boxes, plastic shelving and pieces of wood.

As a result of the finding the facility is found to be non-compliant with item (d) of NFPA 13 Section 5.13.11.

2. While conducting the facility tour during the morning and afternoon hours of 11/02/15 through 11/05/15, numerous areas were observed to be missing lay-in ceiling tiles. As a result of the missing tiles the distance from the sprinkler heads to the decking above, in the areas observed, is in excess of 12 in. (305 mm). As stated above, the maximum allowable distance for the standard pendent sprinkler heads from the decking above is 12 in.

The following locations (but not limited to) were observed during survey as having missing ceiling tiles:

a. The ground floor Equipment Washing Room located off the Department of Corrections corridor.

b. The Utility Closet located in the T-wing of the 11 North Unit.

c. The employee Locker Room located in the 8 north Unit.

d. The Library located on the 1st floor level.

e. The Maintenance Shop labeled Hydro Room on the ground floor level.

3. While conducting the facility tour on the morning of 11/05/15, at approximately 10:45 A.M., it was noted that quick response sprinkler heads are within the same sprinkler compartment as existing light hazard sprinkler heads in the first floor level Dental Suite. One of these quick response sprinkler heads, located at work room #1179, has paint on the glass bulb.

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Based on observations, the facility failed to properly maintain the automatic sprinkler system. Section 2.2.1.1 of the 1998 edition of NFPA 25 "The Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems" requires sprinklers to be free of corrosion, foreign material, paint, and physical damage. Any sprinkler shall be replaced that is painted, corroded damaged, or loaded.

THE FINDINGS INCLUDE:

While conducting the facility tour during the afternoon of 11/05/15, at approximately 1:00 P.M., observations revealed that both the facility's kitchen and outside loading dock are equipped with numerous sprinkler heads that are either loaded with foreign material or damaged by corrosion. As a result of the findings the facility is found to be non-compliant with Section 2.2.1.1 of NFPA 25.

The finding was confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Note: The findings include but are not limited to the afore-mentioned areas.

Based on observations and confirmed by staff, the facility failed to ensure that oxygen is stored in accordance with NFPA 99.

NFPA 99 section Section 4-3.1.1.2 (a)Storage Requirements (Location, Construction, Arrangement) 2. states that enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hr and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.

NFPA 99 section Section 4-3.1.1.2 (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) 3. states the walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.

NFPA 99 section Section 4-3.1.1.2 (b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3) 4. states locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.

NFPA 99 section Section 4-3.1.1.2 (c) Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3)states doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b) (3) and (4) and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.

NFPA 101, LSC, section 8.2.3.2.1 states:
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.

(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

8.2.3.2.3* Opening Protectives.
8.2.3.2.3.1
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42
Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1-hour fire resistance-rated construction, the opening protectives shall be permitted to have not less than a 20-minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test.
Exception No. 2: The requirement of 8.2.3.2.3.1(2) shall not apply where special requirements for doors in 1-hour fire resistance-rated corridor walls and 1-hour fire resistance-rated smoke barriers are specified in Chapters 18 through 21.
Exception No. 3: Existing doors having a 3/4-hour fire protection rating shall be permitted to continue to be used in vertical openings and in exit enclosures in lieu of the 1-hour rating required by 8.2.3.2.3.1(2).

THE FINDINGS INCLUDE:

During the afternoon hours of 11/5/15 it was observed that the Compressed Gas Storage room # 178, located in the Environmental Services area, which stores more than 3000 ft3 of compressed gas, is:

- equipped with a ventilation system that also serves the adjacent office and storage areas. The Compressed Gas Storage room containing greater than 3000 ft3 of compressed gas is required to be vented by a dedicated ventilation system.
- equipped with a non rated corridor door without an automatic closing device. Section 8.2.3.2.3.1 requires the door to have at least a 3/4-hour fire protection rating, and section 8.2.3.2.1(b) requires the door to be self-closing or automatic-closing.
- has unsealed penetrations in the enclosure. NFPA 99, section 4-3.1.1.2(a) 2. requires that the enclosure be constructed with a 1 hr. fire resistive rating.

As a result of the findings the facility is found to be non-compliant with NFPA 99 and NFPA 101.

This was reviewed with facility personnel and acknowledged by the Administrative Staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure the fume hoods are installed in accordance with NFPA 99. NFPA 99, section 5.6.2 states: "Warning signs describing the nature of any hazardous effluent content shall be posted at fume hoods discharge points, access points and filter locations".

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 11/3/15 revealed that the laboratory fume hoods do not have warning signs posted at the discharge points on the roof.

As a result of the findings the facility is found to be non-compliant with NFPA 99, Section 5.6.2

This was acknowledged by a maintenance staff person during the facility tour.

16934


Based on observations and confirmed by staff, the facility failed to ensure compliance with NFPA #70 "National Electric Code".
Section 300-15 states where the wiring method is conduit, electrical metallic tubing, Type AC cable, Type MC cable, Type MI cable, nonmetallic-sheathed cable, or other cables, a box or conduit body complying with Article 370 shall be installed at each conductor splice point, outlet, switch point, junction point, or pull point, unless otherwise permitted in (b) through (n).

THE FINDINGS INCLUDE:

During the the afternoon hours of 11/3/15 while touring the 11 North Unit, two open (uncovered) electrical junction boxes were observed. The non-covered electrical boxes contained line voltage wiring that originally supplied powered to an electric range/oven which has since been removed.

As a result of the findings the facility is found to be non-compliant with NFPA #70 "National Electric Code". Section 300-15

The findings were confirmed by maintenance personnel at time of discovery and acknowledged the Director of Facility Management during the exit conference.

Note: The wiring was provided with electrical wire caps and electrical tape, however the cover plates were missing all together.