St Marys Center Inc

Based on observation and interview, it was determined that the facility did not ensure that exit component enclosures are enclosed with construction having a fire resistive rating of at least one hour in that cable wires and pipe penetrated and passed completely through the firewall in the westside stairwell on floors 2, 3, 4 and 5.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The Finding is:

On December 29, 2011 at approximately 10:53 am, unenclosed vertical cable and pipe penetrations (approximately 3 inches in diameter) were observed in the westside stairwell enclosures on floors 2,3,4,and 5. These wires were not enclosed in proper fire rating material. Facility must make sure that the entire stairwells are fire/smoke protected. All penetrations into the exit stairwell are prohibited except that which serves the stairwell.

In an interview with the maintenance director on 12/29/11 he stated that these wires and pipes are for the Air Conditioning vents located in the corridor and that they exist on each floor. He further stated that this concern will be corrected immediately.

2000 LSC: 19.3.1.1, 8.2.5.2; 10NYCRR 415.29(a)(2), 711.2(a)(1

Based on observation it was determined that the facility did not ensure that doors to hazardous areas were self closing and positively latching in their frames. This was evidenced by the doors to the boiler, gas meter , and sprinkler valve rooms held open by unapproved hold open devices.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy..

The Findings are:

On December 29, 2011 during the Annual Life Safety evaluation of the facility at approximately 11:27 am, it was observed that the following doors were held open by unapproved hold open devices and or did not latch properly when released. These findings were observed in the basement in the following areas; Sprinkler valve room door did not latch in its frame due to rusty nature of the door and frame, Boiler room door hinges were rusty and were maladjusted and therefore could not latch properly, Gas meter room and the Oxygen storage room doors were held open with red soiled linen bin and a broom respectively.

In an interview with the maintenance director on 12/29/11 at approximately 11:30 am, he stated that all these doors will be maintained to latch properly, and all manual devices will be removed.

NFPA 101 2000 19.3.2.1
10NYCRR 711.2(a)(1)

Based on observation, interview and documentation review, it was determined that the facility did not ensure that all fire dampers installed in connection with the ventilating systems equipment are exercised in accordance with NFPA 90 A, standard for the installation Air-Conditioning and Ventilating systems.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

On December 29, 2011 it was observed that the facility is a five story building that is fully sprinklered. Review of maintenance records did not indicate that the dampers were periodically maintained/tested every 4 years in accordance with NFPA 90 A 19.5.2.2.

In an interview with the maintenance director on 12/29/11 he stated that maintenance and testing will be provided for the dampers.

NFPA 90A, 19.5.2.2