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Based on observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

A. At 10:00am on 7/9/13 it was observed that the drywall encasement of the structural beam located in the 2nd floor Mechanical room of 2 South A was not being maintained in accordance with UL Design criteria. The drywall material was not secure to afford a fire protection rating.

B. At 9:26 AM on 7/9/13 it was observed that an area of steel beam approximately six feet in length over the east wall in the Equipment Storage room in the north area of the basement is unprotected and does not meet with NFPA 101, 19.1.6.2 and NFPA 220 (1999) 3-1.

Corridors are not separated from other use spaces in compliance with 19.3.6.1. This deficiency can compromise the use of the exit access corridor during a fire/smoke event.

Findings include:

A. At 1:24 PM on 7/9/13 it was observed that there are two unsealed penetrations above the ceiling in the east wall of the smaller corridor in the first floor administration area. This part of the building is unsprinklered and the corridor wall does not meet NFPA 101, 19.3.6.2.1.

Vertical openings between floors are not protected in compliance with 19.3.1.1 and 8.2.5. This deficiency could result in the effects of fire and smoke on one floor tranferring to another floor level compromising the safety of patients, staff and visitors during a fire/smoke event.

A. At 10:50 AM on 7/9/13 it was observed that there is an unprotected 4 inch hole between floors in the Mechanical room adjacent to the Auditorium on the 1st floor. This penetration was observed from the 2nd floor Mechanical room also. This condition does not meet NFPA 101, 19.3.1.1, 8.2.5.

Smoke barriers are not constructed and maintained in accordance with 19.3.7. These deficiencies could result in the effects of fire and smoke transferring from one side of the smoke barrier to the other and compromising the safety of patients, staff and visitors during a fire/smoke event.

A. At 8:35 AM on 7/9/13 it was observed that there is an unprotected penetration through the smoke barrier located in the North Wing area of the basement. This occurs at the wall adjacent to the smoke damper in the north wall of the closet located off of the east-west corridor and does not meet NFPA 101, 19.3.7.3.

B. At 8:50 AM on 7/9/13 it was observed that there are improperly sealed penetrations through the smoke barrier located in the North Wing area of the basement. This occurs at the east wall of the office located in the Psychological Testing area, and consists of penetrations that were sealed not at the CMU smoke barrier but at the gypsum wall board that is installed on furring channels over the CMU. The gypsum board veneer is not continuous above the ceiling. This condition does not meet NFPA 101, 19.3.7.3.

C. At 11:05 AM on 7/9/13 it was observed that there are unprotected penetrations through the smoke barrier located in the Central Wing area of the first floor in the vestibule of the administration area. These consist of a lack of a smoke damper at a duct penetration in an unsprinklered area, unsealed joints in the gypsum wall board above this duct, and unsealed top of wall conditions, none of which meet NFPA 101, 19.3.7.3.

Smoke barrier doors are not maintained in accordance with 19.3.7.6. This deficiency could result in the effects of fire and smoke transferring from one side of the smoke barrier to the other and compromising the safety of patients, staff and visitors durign a fire/smoke event.

Findings include:

A. At 11:10 AM on 7/9/13 it was observed that the cross corridor doors at the smoke barrier located in the Central Wing of the 1st floor bind at their meeting edges and do not close completely. This condition does not meet NFPA 101, 19.3.7.6.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. At 8:15am on 7/9/13 it was observed that the door to the 3rd floor Gerty building Staff Lounge being used as a storage room lacked a self-closing door to comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5.

B. At 8:20am on 7/9/13 it was observed that the door to the 3rd floor Gerty building Patient Belongings Storage room lacked a self-closing door to comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5. This room is deemed hazardous due to the density of the storage (combustible 'lockers' in a confined space).

C. At 8:20am on 7/9/13 it was observed that the door to the 3rd floor Gerty building Office being used as a storage room lacked a self-closing door to comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5.

D. At 9:05am on 7/9/13 it was observed on the 2nd floor of the Gerty Building that the corridor door to Storage room 200 (adjacent south stair) was not self-closing to a latched condition to comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5.

E. At 10:10am on 7/9/13 it was observed that the unsprinklered Soiled Linen room door (near 250) at the 2nd floor West Wing did not have an observable fire resistance rating label to confirm a minimum 3/4-hour rating to comply with NFPA 101-2000, 19.3.2.1(5).

F. At 11:00am on 7/9/13 it was observed that the unsprinklered Storage room adjacent Patient room #90 on the 1st floor South Wing had a non-functional door closer which did not comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5.

G. At 9:20 AM on 7/9/2013 it was observed that an unsprinklered space located on the east-west corridor of the North Wing area of the basement is labeled on the Life Safety Plan as an " office " is being used for storage. The walls have several unsealed penetrations and do not comply with NFPA 101, 19.3.2.1.

H. At 9:26 AM on 7/9/13 it was observed that the unsprinklered Equipment Storage Room located on the north-south corridor of the North Wing area of the basement did not have complete one hour rated walls because the steel beam that forms the top of the east wall lacks fire protection. NFPA 101, 19.3.2.1. See K012.

I. At 9:40 AM on 7/9/13 it was observed that the unsprinklered office adjacent to the Laboratory located in the North Wing area of the basement is being used for storage. The door between the office and the Laboratory is not ¾ hour fire rated as required to meet NFPA 101, 19.3.2.1.

J. At 9:40 AM on 7/9/13 it was observed that the unsprinklered space labeled " vacant " located on the north-south corridor of the North Wing area of the basement and adjacent to the Laboratory is being used for storage and does not have complete one hour fire rated walls. The top of the south wall is not continuous to the underside of the floor slab above and does not meet NFPA 101, 19.3.2.1.

K. At 9:50 AM on 7/9/13 it was observed that the unsprinklered space labeled " vacant " located adjacent to the Activity Therapy Workroom in the North Wing area of the basement is being used for storage and does not have ¾ hour fire rated doors as required to meet NFPA 101, 19.3.2.1.

L. At 10:10 AM on 7/9/13 it was observed that the unsprinklered office located between Patient Education and Activity Therapy in the central area of the basement is being used for storage and does not have complete one hour fire rated walls. There are unprotected penetrations, the tops of the walls are unsealed and the doors are not ¾ hour fire rated doors as required to meet NFPA 101, 19.3.2.1.

M. At 10:20 AM on 7/9/13 it was observed that the unsprinklered classroom located in the Central Wing area of the basement is being used for storage and does not have complete one hour fire rated walls. There are unsealed penetrations and the tops of the walls are not sealed as required to meet NFPA 101, 19.3.2.1.

N. At 10:57 AM on 7/9/13 it was observed that the unsprinklered closet adjacent to the first floor Auditorium exceeds 50 square feet in area and does not have complete one hour fire rated walls. There are unprotected penetrations and the doors are not ¾ hour fire rated as required to meet NFPA 101, 19.3.2.1.

O. At 1:43 PM on 7/9/13 it was observed that the Soiled Utility room located in the North Wing area of the 1st floor does not have ¾ hour fire rated door as required to meet NFPA 101, 19.3.2.1.

Exit access from portions of smoke compartments is not provided in accordance with 19.2.4.3. Travel from an area of the smoke compartment requires travel into the adjacent smoke compartment to access an exit. This could result in occupants being trapped in a room without access to an exit without entering the smoke compartment of fire/smoke origin.

Findings include:

A. Upon review of the Life Safety reference plans at 2:00pm on 7/8/13 it was observed that the following rooms/areas are provided with exit access doors only through the smoke barrier wall into the adjacent compartment in non-compliance with 19.2.4.3.

1. At the 1st floor Secretary/CEO suite in the North Wing.

2. At the 1st floor Office (used as a visitors' locker) accessed from the Main Lobby in the West Wing.

3. At the 2nd floor Day Room/Offices/Mechanical room near Elevator 'C' in the Central Wing.

Based on observation during the survey walk-through, not all exits are enclosed and/or separated to comply with 7.1.3.2. These deficiencies could affect all patients required to utilize the exit, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 9:00am on 7/9/13 it was observed near the top of the south exit stair of the Gerty building that large electrical box/equipment enclosures were provided and identified as serving old exterior signage. It could not be determined whether this equipment was active or only partially abandoned. This equipment does not serve the stair and is not permitted within the stair enclosure as defined under 7.1.3.2.1(e) and 7.1.3.2.3.

B. At 1:25pm on 7/9/13 it was observed that the door from the Basement Cafeteria to the south stair was not self-closing to comply with 7.1.3.2.1(c) due to friction between the door bottom and the floor surface.

Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.2.3 and 7.2. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching an exit from the building.

Findings include:

A. At 9:00am on 7/9/13 it was observed that the south stair of the Gerty Building used for accessing the roof for servicing of equipment requiring maintenance is not provided with handrails to comply with 7.2.2.4.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 8:30am on 7/9/13 it was observed that the 3rd floor south stair door of the Gerty Building was equipped with a delayed egress device which did not comply with 7.2.1.6.1.

1. The locking device did not release upon activation of the fire alarm system. Surveyor notes that it was not verified at the time of the survey if the device could be released upon actuation of the building sprinkler system, heat detection, or not more than two smoke detectors to comply with 7.2.1.6.1(a). Surveyor also notes that the device controls an electric strike on a stair door rather than a magnetic locking device. If release of the electric strike occurs under fire alarm activation, the door will not remain latched to comply with 8.2.3.2.1.

2. The device was not installed to incorporate an irreversible process to release within 15 seconds upon application of a force to the release device required by 7.2.1.5.4 for a period not to exceed 3 seconds to comply with 7.2.1.6.1(c). The release device was a button on the adjacent wall and not on the door as required by 7.2.1.5.4. The release device required pressing of the button for a continuous 15 seconds before the door would release. The device automatically reset to lock the door upon closing and lacked the manual resetting required by 7.2.1.6.1(c).

3. No signage to comply with 7.2.1.6.1(d) was provided on the door adjacent the release device (door hardware) that reads: "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS".

B. At 10:25am on 7/9/13 it was observed that the 1st floor Gym exterior doors are equipped with panic device hardware and dead bolt locks. The dead bolt and panic device latch constitute two operations to release the door in non-compliance with 7.2.1.5.4. The dead bolt lock installed in connection with the panic hardware prevents the free use of the door for the purpose of egress in non-compliance with 7.2.1.5.6. This condition of locks installed in connection with panic hardware may exist at other locations. Verification of compliance should be reviewed during follow-up visits.

C. At 1:45pm on 7/9/13 it was observed that the 2nd floor Central Wing Social Services Office corridor door was equipped with a latchset and dead bolt lock. The dead bolt and latchset constitute two operations to release the door in non-compliance with 7.2.1.5.4.

D. At 1:47 PM it was observed that the first floor Auditorium is approximately 1,600 square feet in area, which yields an occupant load of 107. The egress door not located in a smoke barrier does not swing in the direction of egress and is not equipped with panic hardware as required by NFPA 101-2000, 19.2.2.2.1, 7.2.1.4.2, 19.1.2.5, 13.2.2.2.3.

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. At 10:45am on 7/9/13 the southwest exterior exit door from the 1st floor Gym was not provided with lighting to comply with 7.8.1.4 for redundant lamps and was not confirmed to be powered from the emergency system to comply with 7.9. Lighting provided was indicated to be high pressure sodium lamp type which does not have instant restrike capability.

B. At 11:00am on 7/9/13 the lighting provided between the South Wing Stair discharge and the southeast Gym exterior exit door appeared to serve the Gym exit door only based upon the location of the lighting relative to the top of the wooden fence. Illumination of the South Wing Stair discharge path was not provided.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. Exit signs are not provided to identify the 2nd means of egress from corridors to comply with 19.2.5.9, 19.2.10.1 and 7.10. Locations noted include the following:

1. At 11:00am on 7/9/13 it was observed that the 1st floor South Wing exit sign placed directly above the south exterior door (which discharged to a locked courtyard) was a directional sign intended to identify the adjacent door to the stair as the exit path. The signage placement directly above a door not intended to be used as the exit can create confusion.

2. At 2:00pm on 7/9/13 it was observed that the corridors serving the 1st floor 'Auditorium' and Offices lacked exit signage at the corridor intersections to identify the exit paths from both directions.

3. At 2:10pm on 7/9/13 it was observed that the corridors near the 2nd floor Nurse Station on 2 North lacked exit signage at the corridor intersection to identify the exit paths from both directions.

Based on observation during the survey walk-through, not all portions of the facility's fire alarm system are installed and maintained in accordance with NFPA 72 1999. These deficiencies can prevent the intiation of the fire alarm system designed to provide early detection of fire conditions.

Findings include:

A. At 1:45pm on 7/9/13 it was observed that the FCPS NAC panels #5 & #6 located at the 2nd floor Mechanical room adjacent the Central Wing Elevator were not provided with labeling to identify the electrical panel and circuit they were being fed from to comply with NFPA 72-1999, 1-5.2.5.2.

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 19.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1.

Findings include:

A. At 10:40am on 7/9/13 it was observed that sprinkler protection to comply with NFPA 13-1999, 5-6.5.3.1 in the 1st floor Gym southeast Storage room was not provided under the thru-wall air duct assembly which exceeded 4' width.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on observation during the survey walk-through, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA 99-1999, 3-4.2.2 and NFPA 70-1999, Section 517, 30-35. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the mixed loads on the panels.

Findings include:

A. Life Safety branch panels throughout the building were observed to have non-life safety loads in non-compliance with NFPA 70-1999, Section 517-32 and NFPA 99-1999, 3-4.2.2.2(b). Life Safety loads were also observed to be on Critical branch panels. Locations observed include but are not necessarily limited to the following:

1. At 8:30am on 7/9/13 it was observed that the LS4 panel located at the 3rd floor electrical room off the Day Room contained building signage, patient room outlets, and others not permitted on the Life Safety branch. The adjacent CR4 Critical branch panel contained emergency light circuits in addition to receptacles.

2. At 3:00pm on 7/9/13 it was observed that the "B" panel "Fed from ATS 2" located in the Electric/storage room behind the 2 North Nurse Station has mixed loads. Circuits included Exit and Emergency lighting and patient room fan coil units and receptacles.

3. At 10:10am on 7/9/13 it was observed that the "A", "B" & "C" panels located at the consultation room adjacent the Nurse Station of the 2 West unit were not clearly identified as to use/function. One panel was labeled as "Fed from ATS 2" but it could not be determined which branch of the emergency power system it was meant to supply because loads appeared to be mixed between those required to be on Life Safety and Critical branch panels. Circuits identified with red markings and provided with lock-on devices appeared to be utilized for Fire Alarm power supply but were not labeled as such.

Based on observation during the survey walk-through, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. These deficiencies could result in exposure of occupants to electrical shock.

Findings include:

A. Electrical panel directories observed typically label blank cover locations as 'spare' rather than as an available 'space' where a circuit breaker may be added. The 'spare' designation is typically reserved for identifying installed circuit breakers which have no connected load. Panel locations observed include but are not limited to:

1. At the 3rd floor Gerty Building electrical room off the Day Room.

2. At the 2nd floor consult room adjacent the 2 West Nurse Station.

3. At the 2nd floor electric/storage room behind the 2 North Nurse Station.

4. At the Basement Kitchen panels and the Cafeteria Storage room.

B. Two circuits in the 'K1' panel in the Kitchen were observed to be tripped and not reset. Circuit 27 & 32 labeled as serving the "Dishwasher room receptacle" and the "salad case" were not confirmed way they had tripped.

Based on observation during the survey walk-through, not all portions of the building are of fire resistive construction in accordance with 19.1.6.2. These deficiencies could affect any patients, staff, or visitors in the building by permitting the building structure to be compromised during fire conditions.

A. At 10:00am on 7/9/13 it was observed that the drywall encasement of the structural beam located in the 2nd floor Mechanical room of 2 South A was not being maintained in accordance with UL Design criteria. The drywall material was not secure to afford a fire protection rating.

B. At 9:26 AM on 7/9/13 it was observed that an area of steel beam approximately six feet in length over the east wall in the Equipment Storage room in the north area of the basement is unprotected and does not meet with NFPA 101, 19.1.6.2 and NFPA 220 (1999) 3-1.

Corridors are not separated from other use spaces in compliance with 19.3.6.1. This deficiency can compromise the use of the exit access corridor during a fire/smoke event.

Findings include:

A. At 1:24 PM on 7/9/13 it was observed that there are two unsealed penetrations above the ceiling in the east wall of the smaller corridor in the first floor administration area. This part of the building is unsprinklered and the corridor wall does not meet NFPA 101, 19.3.6.2.1.

Vertical openings between floors are not protected in compliance with 19.3.1.1 and 8.2.5. This deficiency could result in the effects of fire and smoke on one floor tranferring to another floor level compromising the safety of patients, staff and visitors during a fire/smoke event.

A. At 10:50 AM on 7/9/13 it was observed that there is an unprotected 4 inch hole between floors in the Mechanical room adjacent to the Auditorium on the 1st floor. This penetration was observed from the 2nd floor Mechanical room also. This condition does not meet NFPA 101, 19.3.1.1, 8.2.5.

Smoke barriers are not constructed and maintained in accordance with 19.3.7. These deficiencies could result in the effects of fire and smoke transferring from one side of the smoke barrier to the other and compromising the safety of patients, staff and visitors during a fire/smoke event.

A. At 8:35 AM on 7/9/13 it was observed that there is an unprotected penetration through the smoke barrier located in the North Wing area of the basement. This occurs at the wall adjacent to the smoke damper in the north wall of the closet located off of the east-west corridor and does not meet NFPA 101, 19.3.7.3.

B. At 8:50 AM on 7/9/13 it was observed that there are improperly sealed penetrations through the smoke barrier located in the North Wing area of the basement. This occurs at the east wall of the office located in the Psychological Testing area, and consists of penetrations that were sealed not at the CMU smoke barrier but at the gypsum wall board that is installed on furring channels over the CMU. The gypsum board veneer is not continuous above the ceiling. This condition does not meet NFPA 101, 19.3.7.3.

C. At 11:05 AM on 7/9/13 it was observed that there are unprotected penetrations through the smoke barrier located in the Central Wing area of the first floor in the vestibule of the administration area. These consist of a lack of a smoke damper at a duct penetration in an unsprinklered area, unsealed joints in the gypsum wall board above this duct, and unsealed top of wall conditions, none of which meet NFPA 101, 19.3.7.3.

Smoke barrier doors are not maintained in accordance with 19.3.7.6. This deficiency could result in the effects of fire and smoke transferring from one side of the smoke barrier to the other and compromising the safety of patients, staff and visitors durign a fire/smoke event.

Findings include:

A. At 11:10 AM on 7/9/13 it was observed that the cross corridor doors at the smoke barrier located in the Central Wing of the 1st floor bind at their meeting edges and do not close completely. This condition does not meet NFPA 101, 19.3.7.6.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with NFPA 101-2000, 19.3.2.1 and 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the exit access in the event of a fire condition.

Findings include:

A. At 8:15am on 7/9/13 it was observed that the door to the 3rd floor Gerty building Staff Lounge being used as a storage room lacked a self-closing door to comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5.

B. At 8:20am on 7/9/13 it was observed that the door to the 3rd floor Gerty building Patient Belongings Storage room lacked a self-closing door to comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5. This room is deemed hazardous due to the density of the storage (combustible 'lockers' in a confined space).

C. At 8:20am on 7/9/13 it was observed that the door to the 3rd floor Gerty building Office being used as a storage room lacked a self-closing door to comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5.

D. At 9:05am on 7/9/13 it was observed on the 2nd floor of the Gerty Building that the corridor door to Storage room 200 (adjacent south stair) was not self-closing to a latched condition to comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5.

E. At 10:10am on 7/9/13 it was observed that the unsprinklered Soiled Linen room door (near 250) at the 2nd floor West Wing did not have an observable fire resistance rating label to confirm a minimum 3/4-hour rating to comply with NFPA 101-2000, 19.3.2.1(5).

F. At 11:00am on 7/9/13 it was observed that the unsprinklered Storage room adjacent Patient room #90 on the 1st floor South Wing had a non-functional door closer which did not comply with NFPA 101-2000, 18.3.2.1, 8.4.1.2 and 8.2.4.3.5.

G. At 9:20 AM on 7/9/2013 it was observed that an unsprinklered space located on the east-west corridor of the North Wing area of the basement is labeled on the Life Safety Plan as an " office " is being used for storage. The walls have several unsealed penetrations and do not comply with NFPA 101, 19.3.2.1.

H. At 9:26 AM on 7/9/13 it was observed that the unsprinklered Equipment Storage Room located on the north-south corridor of the North Wing area of the basement did not have complete one hour rated walls because the steel beam that forms the top of the east wall lacks fire protection. NFPA 101, 19.3.2.1. See K012.

I. At 9:40 AM on 7/9/13 it was observed that the unsprinklered office adjacent to the Laboratory located in the North Wing area of the basement is being used for storage. The door between the office and the Laboratory is not ¾ hour fire rated as required to meet NFPA 101, 19.3.2.1.

J. At 9:40 AM on 7/9/13 it was observed that the unsprinklered space labeled " vacant " located on the north-south corridor of the North Wing area of the basement and adjacent to the Laboratory is being used for storage and does not have complete one hour fire rated walls. The top of the south wall is not continuous to the underside of the floor slab above and does not meet NFPA 101, 19.3.2.1.

K. At 9:50 AM on 7/9/13 it was observed that the unsprinklered space labeled " vacant " located adjacent to the Activity Therapy Workroom in the North Wing area of the basement is being used for storage and does not have ¾ hour fire rated doors as required to meet NFPA 101, 19.3.2.1.

L. At 10:10 AM on 7/9/13 it was observed that the unsprinklered office located between Patient Education and Activity Therapy in the central area of the basement is being used for storage and does not have complete one hour fire rated walls. There are unprotected penetrations, the tops of the walls are unsealed and the doors are not ¾ hour fire rated doors as required to meet NFPA 101, 19.3.2.1.

M. At 10:20 AM on 7/9/13 it was observed that the unsprinklered classroom located in the Central Wing area of the basement is being used for storage and does not have complete one hour fire rated walls. There are unsealed penetrations and the tops of the walls are not sealed as required to meet NFPA 101, 19.3.2.1.

N. At 10:57 AM on 7/9/13 it was observed that the unsprinklered closet adjacent to the first floor Auditorium exceeds 50 square feet in area and does not have complete one hour fire rated walls. There are unprotected penetrations and the doors are not ¾ hour fire rated as required to meet NFPA 101, 19.3.2.1.

O. At 1:43 PM on 7/9/13 it was observed that the Soiled Utility room located in the North Wing area of the 1st floor does not have ¾ hour fire rated door as required to meet NFPA 101, 19.3.2.1.

Exit access from portions of smoke compartments is not provided in accordance with 19.2.4.3. Travel from an area of the smoke compartment requires travel into the adjacent smoke compartment to access an exit. This could result in occupants being trapped in a room without access to an exit without entering the smoke compartment of fire/smoke origin.

Findings include:

A. Upon review of the Life Safety reference plans at 2:00pm on 7/8/13 it was observed that the following rooms/areas are provided with exit access doors only through the smoke barrier wall into the adjacent compartment in non-compliance with 19.2.4.3.

1. At the 1st floor Secretary/CEO suite in the North Wing.

2. At the 1st floor Office (used as a visitors' locker) accessed from the Main Lobby in the West Wing.

3. At the 2nd floor Day Room/Offices/Mechanical room near Elevator 'C' in the Central Wing.

Based on observation during the survey walk-through, not all exits are enclosed and/or separated to comply with 7.1.3.2. These deficiencies could affect all patients required to utilize the exit, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 9:00am on 7/9/13 it was observed near the top of the south exit stair of the Gerty building that large electrical box/equipment enclosures were provided and identified as serving old exterior signage. It could not be determined whether this equipment was active or only partially abandoned. This equipment does not serve the stair and is not permitted within the stair enclosure as defined under 7.1.3.2.1(e) and 7.1.3.2.3.

B. At 1:25pm on 7/9/13 it was observed that the door from the Basement Cafeteria to the south stair was not self-closing to comply with 7.1.3.2.1(c) due to friction between the door bottom and the floor surface.

Based on observation during the survey walk-through, not all stairs are constructed and maintained in accordance with 19.2.2.3 and 7.2. These deficiencies could affect all persons required to utilize the exit components by preventing those occupants from safely reaching an exit from the building.

Findings include:

A. At 9:00am on 7/9/13 it was observed that the south stair of the Gerty Building used for accessing the roof for servicing of equipment requiring maintenance is not provided with handrails to comply with 7.2.2.4.

Based on observation during the survey walk-through, not all exit doors are arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients in the area of the facility, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the building.

Findings include:

A. At 8:30am on 7/9/13 it was observed that the 3rd floor south stair door of the Gerty Building was equipped with a delayed egress device which did not comply with 7.2.1.6.1.

1. The locking device did not release upon activation of the fire alarm system. Surveyor notes that it was not verified at the time of the survey if the device could be released upon actuation of the building sprinkler system, heat detection, or not more than two smoke detectors to comply with 7.2.1.6.1(a). Surveyor also notes that the device controls an electric strike on a stair door rather than a magnetic locking device. If release of the electric strike occurs under fire alarm activation, the door will not remain latched to comply with 8.2.3.2.1.

2. The device was not installed to incorporate an irreversible process to release within 15 seconds upon application of a force to the release device required by 7.2.1.5.4 for a period not to exceed 3 seconds to comply with 7.2.1.6.1(c). The release device was a button on the adjacent wall and not on the door as required by 7.2.1.5.4. The release device required pressing of the button for a continuous 15 seconds before the door would release. The device automatically reset to lock the door upon closing and lacked the manual resetting required by 7.2.1.6.1(c).

3. No signage to comply with 7.2.1.6.1(d) was provided on the door adjacent the release device (door hardware) that reads: "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS".

B. At 10:25am on 7/9/13 it was observed that the 1st floor Gym exterior doors are equipped with panic device hardware and dead bolt locks. The dead bolt and panic device latch constitute two operations to release the door in non-compliance with 7.2.1.5.4. The dead bolt lock installed in connection with the panic hardware prevents the free use of the door for the purpose of egress in non-compliance with 7.2.1.5.6. This condition of locks installed in connection with panic hardware may exist at other locations. Verification of compliance should be reviewed during follow-up visits.

C. At 1:45pm on 7/9/13 it was observed that the 2nd floor Central Wing Social Services Office corridor door was equipped with a latchset and dead bolt lock. The dead bolt and latchset constitute two operations to release the door in non-compliance with 7.2.1.5.4.

D. At 1:47 PM it was observed that the first floor Auditorium is approximately 1,600 square feet in area, which yields an occupant load of 107. The egress door not located in a smoke barrier does not swing in the direction of egress and is not equipped with panic hardware as required by NFPA 101-2000, 19.2.2.2.1, 7.2.1.4.2, 19.1.2.5, 13.2.2.2.3.

Based on random observation during the survey walk-through, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way.

Findings include:

A. At 10:45am on 7/9/13 the southwest exterior exit door from the 1st floor Gym was not provided with lighting to comply with 7.8.1.4 for redundant lamps and was not confirmed to be powered from the emergency system to comply with 7.9. Lighting provided was indicated to be high pressure sodium lamp type which does not have instant restrike capability.

B. At 11:00am on 7/9/13 the lighting provided between the South Wing Stair discharge and the southeast Gym exterior exit door appeared to serve the Gym exit door only based upon the location of the lighting relative to the top of the wooden fence. Illumination of the South Wing Stair discharge path was not provided.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. Exit signs are not provided to identify the 2nd means of egress from corridors to comply with 19.2.5.9, 19.2.10.1 and 7.10. Locations noted include the following:

1. At 11:00am on 7/9/13 it was observed that the 1st floor South Wing exit sign placed directly above the south exterior door (which discharged to a locked courtyard) was a directional sign intended to identify the adjacent door to the stair as the exit path. The signage placement directly above a door not intended to be used as the exit can create confusion.

2. At 2:00pm on 7/9/13 it was observed that the corridors serving the 1st floor 'Auditorium' and Offices lacked exit signage at the corridor intersections to identify the exit paths from both directions.

3. At 2:10pm on 7/9/13 it was observed that the corridors near the 2nd floor Nurse Station on 2 North lacked exit signage at the corridor intersection to identify the exit paths from both directions.

Based on observation during the survey walk-through, not all portions of the facility's fire alarm system are installed and maintained in accordance with NFPA 72 1999. These deficiencies can prevent the intiation of the fire alarm system designed to provide early detection of fire conditions.

Findings include:

A. At 1:45pm on 7/9/13 it was observed that the FCPS NAC panels #5 & #6 located at the 2nd floor Mechanical room adjacent the Central Wing Elevator were not provided with labeling to identify the electrical panel and circuit they were being fed from to comply with NFPA 72-1999, 1-5.2.5.2.

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 19.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1.

Findings include:

A. At 10:40am on 7/9/13 it was observed that sprinkler protection to comply with NFPA 13-1999, 5-6.5.3.1 in the 1st floor Gym southeast Storage room was not provided under the thru-wall air duct assembly which exceeded 4' width.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the Interim Life Safety Measures to remain in place as work toward the completion of its PoC progresses.

Based on observation during the survey walk-through, the surveyor found that the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA 99-1999, 3-4.2.2 and NFPA 70-1999, Section 517, 30-35. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the mixed loads on the panels.

Findings include:

A. Life Safety branch panels throughout the building were observed to have non-life safety loads in non-compliance with NFPA 70-1999, Section 517-32 and NFPA 99-1999, 3-4.2.2.2(b). Life Safety loads were also observed to be on Critical branch panels. Locations observed include but are not necessarily limited to the following:

1. At 8:30am on 7/9/13 it was observed that the LS4 panel located at the 3rd floor electrical room off the Day Room contained building signage, patient room outlets, and others not permitted on the Life Safety branch. The adjacent CR4 Critical branch panel contained emergency light circuits in addition to receptacles.

2. At 3:00pm on 7/9/13 it was observed that the "B" panel "Fed from ATS 2" located in the Electric/storage room behind the 2 North Nurse Station has mixed loads. Circuits included Exit and Emergency lighting and patient room fan coil units and receptacles.

3. At 10:10am on 7/9/13 it was observed that the "A", "B" & "C" panels located at the consultation room adjacent the Nurse Station of the 2 West unit were not clearly identified as to use/function. One panel was labeled as "Fed from ATS 2" but it could not be determined which branch of the emergency power system it was meant to supply because loads appeared to be mixed between those required to be on Life Safety and Critical branch panels. Circuits identified with red markings and provided with lock-on devices appeared to be utilized for Fire Alarm power supply but were not labeled as such.

Based on observation during the survey walk-through, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. These deficiencies could result in exposure of occupants to electrical shock.

Findings include:

A. Electrical panel directories observed typically label blank cover locations as 'spare' rather than as an available 'space' where a circuit breaker may be added. The 'spare' designation is typically reserved for identifying installed circuit breakers which have no connected load. Panel locations observed include but are not limited to:

1. At the 3rd floor Gerty Building electrical room off the Day Room.

2. At the 2nd floor consult room adjacent the 2 West Nurse Station.

3. At the 2nd floor electric/storage room behind the 2 North Nurse Station.

4. At the Basement Kitchen panels and the Cafeteria Storage room.

B. Two circuits in the 'K1' panel in the Kitchen were observed to be tripped and not reset. Circuit 27 & 32 labeled as serving the "Dishwasher room receptacle" and the "salad case" were not confirmed way they had tripped.