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Based on observations and confirmed by staff, corridor walls are not constructed as required.

THE FINDINGS INCLUDE:

-During the morning and afternoon hours of October 18, 2011 while touring the facility, it was observed that corridor walls surrounding the surgery suite have penetrations. The area is not fully sprinklered.
Penetrations were found in corridor walls above the suspended ceilings in the following areas:

1) Near the special procedure room there is one "bx" type electrical cable and one 1-1/2 inch type electrical conduit that are not properly sealed.

2) At the cross-corridor doors near the ortho room there are two "bx" electrical cables that are not properly sealed.

3) At the nursing station there is a 3-1/2 foot by 2-1/2 foot hole.

4) Near the door to the center core of the Surgery Suite there are 4 "bx" electrical cables that are not properly sealed.

5) At the cross-corridor doors near OR # 5 the wall does not continue to the deck above. The wall stops 3 feet short of the deck above.

These were each acknowledged by hospital staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that doors hazardous area's are held open by approved devices. Section 19.2.2.2.6 states any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
Section 7.2.1.8.2 states that in any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.
Section 2-10.6.2 states smoke detectors that are used exclusively for smoke door release service shall be located and spaced as required by 2-10.6. Section 2-10.6.5.1.1 states if the depth of wall section above the door is 24 in. (610 mm) or less, one ceiling-mounted detector shall be required on one side of the doorway only located at a maximum of five feet (5') from the door. Section 2-10.6.5.1.1 states if the wall section above the door is greater than twenty four inches (24") then a ceiling mounted detector is to be mounted on each side of the door way.

THE FINDINGS INCLUDE:

- During the morning hours of October 18, 2011 while touring the facility, it was observed that the corridor double doors to the West basement level central storage room are held open with electronic magnetic devices. There is no smoke detector located on either side of the corridor doors.
Note: The basement corridors are not protected throughout by smoke detecting devices per NFPA 72.

This was acknowledged by hospital staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

- During the morning hours of October 18, 2011 while touring the facility, it was observed that the door to West basement level central storage room is lacking a self closing device.
Note: This door is within the Plant Operations office area.

This was acknowledged by hospital staff during the exit interview process.

Based on observations, the facility failed to assure that stair landings are kept clear in accordance with the requirements. Section 7.2.2.5.3 requires that there be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure.

THE FINDINGS INCLUDE:

Main Building - SCM Wing

- Observations while touring the facility on the morning of October 18, 2011 revealed two (2) housekeeping carts stored in the basement landing of stairway #4.
This was confirmed by the a facility maintenance staff person.

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.
Section 7.2.2.4.1 states means of egress that are more than 30 in. (76 cm) above the floor or grade below shall be provided with guards to prevent falls over the open side. Means of egress components that might require protection with guards include stairs, landings, balconies, corridors, passageways, floor or roof openings, ramps, aisles, porches, and mezzanines.
Section 7.2.2.4.6 states guard details shall be as follows:
(1) The height of guards required in 7.2.2.4.1 shall be measured vertically to the top of the guard from the surface adjacent thereto.
(2) Guards shall be not less than 42 in. (107 cm) high.
(3) Open guards, other than approved, existing open guards, shall have intermediate rails or an ornamental pattern such that a sphere 4 in. (10.1 cm) in diameter shall not pass through any opening up to a height of 34 in. (86 cm).
Section 7.2.5.3.1 states ramp construction shall be as follows.
(a) All ramps serving as required means of egress shall be of permanent fixed construction.
(b) Each ramp in buildings required by this Code to be of Type I or Type II construction shall be noncombustible or limited-combustible throughout. The ramp floor and landings shall be solid and without perforations.
Section 7.2.5.2 states (2) existing ramps shall be permitted to remain in use or be rebuilt, provided that they meet the requirements shown in Table 7.2.5.2(b). This table permits a maximum slope of 1" of rise in 8" of run.

THE FINDINGS INCLUDE:

- During the morning hours of October 19, 2011 while touring the facility, the following items were observed regarding required egress routes:

1) The Elderly Behavorial Health Serve (EBHS) unit has a total of four locked doors in which three of these doors require a key to open. Various staff members were asked to present their keys to unlock the doors. A total of two staff members did not have the proper keys to unlock the doors. A third staff member did have the key, but was unaware that she did in fact have it on her key chain. This particular staff member stated "I do not have that key, I'm only a house-keeper".

2) Stairwell #6 terminates to the facility loading dock which is approximately 48" above grade level. The loading dock which is accessible to all exiting the stairwell is not equipped with any guard system to prevent personnel from falling from the platform.

3) The stairs leading from the loading dock which are a required means of egress are no longer accessible. They have been covered over with a ramp constructed entirely of wood.

4) The wood ramp mentioned in item #3 has a slope of 1" of rise in 4" of run and does not fall within ramp specifications.

These were each acknowledged by hospital staff during the exit interview process.

Based on observations, the facility failed to assure that corridors are at least 8 feet wide. Section 4.6.7 prohibits existing life safety features that exceed the requirements for existing buildings, to be diminished. Section 4.6.7 requiems facilities constructed with corridors up to 8 feet in width maintain the width. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no objects be so placed so as to obstruct exits, access thereto, egress therefrom, or visibility thereof.

THE FINDINGS INCLUDE:

Main Building - SCM Wing

- Observations while touring the facility on the morning of October 17, 2011 revealed computers on wheels (COWS) stored in the corridors plugged into receptacles at charging stations set up by rooms 108, 112, 210, 215, 230, 234 and 238.
This was confirmed by the a facility maintenance staff person.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

- During the morning hours of October 18, 2011 while touring the facility, it was observed that light switches controlling egress lighting are accessible by the general public. When these switches were tested for operation, the entire egress route was left in complete darkness. The switches which were observed but not limited to include the following locations:

1) The 1st floor corridor switch by elevator #6 shuts off the entire corridor.

2) Stair #6 has a switch at ground level which shuts off the stairwell lighting.

These were each acknowledged by hospital staff during the exit interview process.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.
NFPA 101 section 4.6.12.1 requires any device, equipment, system, condition, arrangement, level of protection or any other feature required for compliance with the provision of this code to be continuously maintained in accordance with applicable NFPA requirements. "Central Sprinkler Corporation" has numerous sprinkler heads manufactured from the mid 1970's through 2001 which have been determined to be defective and must be replaced.

THE FINDINGS INCLUDE:

- During the morning hours of October 19, 2011 while touring the facility, the following items were observed regarding sprinkler systems:

1) The facility has a total of three dry type sprinkler systems. After reviewing records and examining the valves, it was observed that weekly sprinkler pressure readings are not documented.
Note: It was stated by staff that the systems are "looked at during rounds", but actual pressure readings are not recorded.

2) The parking garage adjacent to the Thayer building has an approximate total of 56 recalled sprinkler heads. The sprinkler heads in question which are also corroded, are "1992 Central A-1" dry type heads.

3) The parking garage adjacent to the Main building has an approximate total of 12 recalled sprinkler heads. The sprinkler heads in question which are also corroded, are "1995 Central GB" type heads.
Note: For some unknown reason, more than three quarters of the sprinkler heads in this garage were already replaced, only leaving these 12 sprinkler heads as defective.

These were each acknowledged by hospital staff during the exit interview process.

Based on observations, the facility failed to ensure that portable electric heaters are prohibited from the building.

THE FINDINGS INCLUDE:

Main Building - SCM Wing
- Observations while touring the facility on the afternoon of October 17, 2011 revealed portable electric heaters in the two (2) coding offices located on the ground floor by the auditorium.
This was confirmed by the a facility maintenance staff person.

Based on record review and confirmed by interview, the facility failed to ensure that medical gas systems and bulk oxygen tank are in accordance with NFPA 50 and 99.
NFPA 99, Section 4.3.1.1.2(a)10b and NFPA 50, Section 4.2.2 requires weeds and long grass within 15 feet of the bulk oxygen tank to be cut back.
NFPA 99, Section 4.3.2.1.9 requires outdoor exhausts to be protected against the entry of insects, vermin, debris, and precipitation. Section 4.3.1.2.3 requires shut off valves accessible to other than authorized personnel to be installed in valve boxes with frangible or removable windows. Section 4.3.1.2.3(m) requires valves to be readily accessible in an emergency.

THE FINDINGS INCLUDE:

Main Building - SCM Wing
1. Observations while touring the facility on the morning of October 18, 2011 revealed that weeds are growing within 15 feet of one of the bulk oxygen tanks. Some are so close that they come in contact with it.

2. Observations while touring the facility on the afternoon of October 18, 2011 revealed that the vacuum pump exhaust pipes located on the roofs are not protected against the entry of insects, vermin and debris.

3. Observations while touring the facility on the morning of October 17, 2011 revealed that the medical gas emergency shut off valve boxes in the first floor Elderly Behavorial Health Service Unit are not readily accessible. The valve boxes have Plexiglass type covers that are screwed in place.

These were acknowledged by a maintenance staff person during the facility tour.

Based on observation and confirmed by staff, the facility failed to ensure that smoke dampers are installed as required. LSC Section 8.3.5.1 requires an approved damper designed to resist the passage of smoke to be provided for each air transfer opening or duct penetration of a required smoke barrier. Section 8.3.5.2 requires smoke dampers in ducts penetrating smoke barriers to close upon detection of smoke by approved smoke detectors in accordance with NFPA 72.

THE FINDINGS INCLUDE:

- During the morning hours of October 18, 2011 while touring the facility, it was observed that the smoke barrier wall on both the 1st and 2nd floors of the SCM wing have duct penetrations that are not equipped with smoke dampers. Each smoke barrier wall has an approximate 12" x 16" duct penetrating the wall.
Note: The smoke compartments adjacent to each smoke barrier wall are not fully sprinklered to meet the exception to the code.

This was acknowledged by hospital staff during the exit interview process.

Morton Health Services (Building 14)
511 West Grove Street, Middleborough, MA

Based on observations, the facility failed to maintain the fire alarm system in accordance with NFPA 72. LSC Sections 39.3.4.1 and 9.6.1.4 requires fire alarm system to be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, tests, and maintenance of the fire alarm system to be provided including detailed information as to the results.

THE FINDINGS INCLUDE:

- Observations while touring the building on the afternoon of October 18, 2011 revealed that the fire alarm panel was in trouble. The facility had no records available to substantiate that the trouble has been addressed, that the system was functional and arrangement had been made to repair it.

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 October 18, 2011 revealed that the laboratory fume hoods do not have warning signs posted at the discharge points on the roof.
This was acknowledged by a maintenance staff person during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that all existing elevators conform with the proper Firefighter's Service Requirements where required.

THE FINDINGS INCLUDE:

- During the morning hours of October 19, 2011 while touring the facility, it was observed that the two elevators located adjacent to the main kitchen are not equipped with Firefighter's Service Requirements of ASME/ANSI A17.3. Each of these elevators travel to the fourth floor level above grade exceeding the 25 foot allowance and are required to meet Phase I and Phase II Firefighter's Service Requirements.

This was acknowledged by hospital 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 October 18, 2011 revealed that the laboratory fume hoods do not have warning signs posted at the discharge points on the roof.
This was acknowledged by a maintenance staff person during the facility tour.