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Based on observations and confirmed by staff, the facility failed to ensure that the roof is properly separated from the remaining portion of the building.

Section 19.1.6.2 states any building of Type I(442), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that all of the following criteria are met:
(1) The roof covering shall meet Class C requirements in accordance with ASTM E 108, Standard Test Methods for Fire Tests of Roof Coverings, or ANSI/UL 790, Test Methods for Fire Tests of Roof Coverings.
(2) The roof shall be separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 2-1/2 in. (63 mm) of concrete or gypsum fill.
(3) The attic or other space shall be either unoccupied or protected throughout by an approved automatic sprinkler system.

Section 19.1.6.3 states any building of Type I(442), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that all of the following criteria are met:
(1) The roof covering shall meet Class A requirements in accordance with ASTM E 108, Standard Test Methods for Fire Tests of Roof Coverings, or ANSI/UL 790, Test Methods for Fire Tests of Roof Coverings.
(2) The roof/ceiling assembly shall be constructed with fire retardant-treated wood meeting the requirements of NFPA 220, Standard on Types of Building Construction.
(3) The roof/ceiling assembly shall have the required fire resistance rating for the type of construction.

NFPA 703 section 4.5 states fire retardant-treated lumber and wood structural panels shall be labeled and listed with the following information:
(1) Identification mark of an approved agency that lists materials in accordance with Chapter 3 (See 3.2.4, Listed.)
(2) Identification of the treating manufacturer
(3) Name of the fire-retardant treatment
(4) Species of wood treated
(5) End use of the product
(6) Flame spread index and smoke developed index
(7) Method of drying after treatment
(8) Verification of conformance with appropriate standards in accordance with Sections 4.2 through 4.4
(9) The words "No increase in the listed classification when subjected to the Standard Rain Test [ASTM D 2898 (Method A)]," for fire retardant-treated wood exposed to weather or to damp or wet locations

THE FINDINGS INCLUDE:

During the morning hours of 3/13/17 while viewing the architectural plans provided by the facility, it was observed that the building was constructed as a Type II (222) building classification. After review of the plans, it was revealed that the facility has two (2) gable style roofs constructed with plywood sheathing. The two roofs which are each approximately 42' x 180' in size are constructed with 3/4" exterior grade plywood sheathing laid on top of light gauge aluminum trusses.

During the afternoon hours of 3/15/17 the gable style roof of the facility was viewed for structural integrity. It was observed that the plywood sheathing was not labeled as being fire retardant-treated wood. The sheathing was viewed in numerous locations as it is readily observable from the attic location, no labels were observed in any of the locations. It was later stated by facility staff, that the plywood sheathing which was used is not fire retardant. It was further stated that in lieu of the fire retardant sheathing, a dry pipe sprinkler was utilized.
Note: The architectural plans specify that the plywood sheathing is 3/4" exterior grade.

In addition, the facility installed a separation between the roof assembly and the floor below consisting of a hard pan ceiling approximately 4' above the corridor lay-in ceiling tiles. The ceiling was observed to consist of a single layer of 5/8" type X gypsum material.

As a result of the plywood sheathing being non-fire retardant and the roof assembly not having the proper separation, the facility failed to comply with sections 19.1.6.2 and 19.1.6.3.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that horizontal exits are maintained as required.

Section 19.2.2.5 states horizontal exits complying with 7.2.4 and the modifications of 19.2.2.5.1 through 19.2.2.5.4 shall be permitted.

Section 7.2.4.3.1 states fire barriers separating buildings or areas between which there are horizontal exits shall have a minimum 2-hour fire resistance rating, unless otherwise provided in 7.2.4.4.1, and shall provide a separation that is continuous to the finished ground level.

THE FINDINGS INCLUDE:

During the afternoon hours of 3/13/17 at approximately 2:45 P.M. while surveying the 1 North Unit, the 2-hour fire barrier wall was viewed for structural integrity. The wall was observed to be incomplete above door #1022D. There is an approximate 5' x 3' section of wall which was not in place in the required 2-hour fire barrier. According to staff interview, the wall may have been shifted due to an access panel in a piece of duct work.

As a result of the missing section of wall, the facility failed to comply with section 7.2.4.3.1 requiring a 2-hour separation between the separate occupancies.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that egress routes are constructed as required.

Section 7.7.1 states exits shall terminate directly at a public way or at an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.

Section 7.7.1.1 states yards, courts, open spaces, or other portions of the exit discharge shall be of the required width and size to provide all occupants with a safe access to a public way.

THE FINDINGS INCLUDE:

During the morning hours of 3/13/17, it was observed that exterior egress route between stair #4 and stair #3 has not been completed with a hard packed surface. As currently situated, the walkway consists of crushed stone and gravel. In addition, there is a 4' x 8' sheet of plywood placed directly over a muddy area at the exterior of stairwell #4.

As a result, stairwell #4 is not equipped with a hard packed walkway to ensure the means of egress is always free of obstructions that would prevent its use, such as ice, sleet, snow and the need for its removal in climates such as the Northeast region as required by section 7.7.1.1.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler systems are installed in accordance with NFPA 13 "Standard for the Installation of Sprinkler Systems".

Section 8.15.10.1 states unless the requirements of 8.15.10.3 are met, sprinkler protection shall be required in electrical equipment rooms.

8.15.10.3 states sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met:
(1) The room is dedicated to electrical equipment only.
(2) Only dry-type electrical equipment is used.
(3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(4) No combustible storage is permitted to be stored in the room.

Section 8.6.4.1.1.1 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) throughout the area of coverage of the sprinkler.

Section 7.1.1.2 states pressure gauges shall be installed above and below each alarm check valve or system riser check valve where such devices are present.

THE FINDINGS INCLUDE:

While conducting the facility tour during 3/13/17 and 3/15/17, the following observations were observed regarding the sprinkler system:

1) The non-rated electrical closet located in the Care Access Unit was not equipped with sprinkler protection.

2) Observations revealed that the facility's main kitchen was inadequately protected by the automatic sprinkler system. This is due to the fact that there are two 10" x 14" voids in the ceiling plane between the two kitchen range hoods. The voids create an unprotected area above the kitchen ceiling. In order to adequately protect the area, the voids need to be eliminated or protection must be added above the ceiling.

3) The automatic sprinkler system main, located in the basement, was equipped with a backflow valve (check valve) before the system riser. There was no pressure gauge installed below the backflow valve.

As a result, the facility failed to comply with section 8.15.10.3, 8.6.4.1.1.1 and section 7.1.1.2 of NFPA 13.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities during the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 6 of the 2012 edition of NFPA 10 "Standard for Portable Fire Extinguishers".

Chapter 6 Section 6.1.3.3.2 states that in large rooms and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.

Section 6.1.3.10.2 states that the location of fire extinguishers as described in 6.1.3.3.2 shall be marked conspicuously.

THE FINDINGS INCLUDE:

While conducting the facility tour on both 3/13/17 and 3/15/17, observations revealed that the majority of fire extinguishers are located in recessed wall cabinets. The wall cabinets lack signage which conspicuously mark their location as they can not be identified when traversing the corridors.

As a result of the finding the facility is found to be non-compliant with Chapter 6 section 6.1.3.10.2.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that corridor separation is provided as required.

Section 19.3.6.1 subsection (7) states spaces other than patient sleeping rooms, treatment rooms, and hazardous areas, shall be permitted to be open to the corridor and unlimited in area, provided that all of the following criteria are met:

(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are
protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all
other combustibles within the area, are of such minimum quantity and arrangement that a fully developed
fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

Section 19.3.6.1 subsection (8) states waiting areas shall be permitted to be open to the corridor, provided that all of the following criteria are met:

(a) Each area does not exceed 600 ft2 (55.7 m2).
(b) The area is equipped with an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(c) The area does not obstruct any access to required exits.

THE FINDINGS INCLUDE:

While conducting the facility tour during the morning and afternoon hours of 3/13/17 and 3/15/17, the following locations were observed open to the corridor:

1) The Intake/Reception Office adjacent to the ambulance entrance is considered open to the corridor. This location is not equipped with an electrically supervised automatic smoke detector.

2) The Waiting Room adjacent to the ambulance entrance is considered open to the corridor. This location is not equipped with an electrically supervised automatic smoke detector.

As a result, the facility failed to comply with section 19.3.6.1 regarding rooms open to the corridor.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that all corridor doors close, latch, and form a smoke resistant barrier.

Section 19.3.6.3.1 states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:

(1) 1-3/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 3/13/17 and 3/15/17, it was observed that each of the five (5) Medication Rooms are equipped with 25" x 36" pass through doors. Each of these doors (9 total) is equipped with a hook and eye style latching mechanism. However as installed, the doors do not sit tight into the door frames, leaving an approximate 1/4" gap at the latching side.

As a result, the facility failed to comply with section 19.3.6.3.1 requiring doors to the corridor to be smoke resistant.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that the Heating Ventilation Air Conditioning (HVAC) System is installed as required..

Section 19.5.2.1 states heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19.5.2.2.

Section 9.2.1 states Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A section 4.3.12.1.1 states egress corridors in nursing and long term care facilities, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.3.1 through 4.3.12.1.3.4.

THE FINDINGS INCLUDE:

While conducting the facility tour on both 3/13/17 and 3/15/17, observations revealed that each of the care units had a small room containing residential style clothes washers and dryers. Each of these rooms was equipped with a supply diffuser only and no means of returning the air to the HVAC system.

As a result, the facility failed to comply with NFPA 90A section 4.3.12.1 prohibiting the use of egress corridors as a portion of a return air system.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities during the exit conference.

Based on documentation review and staff interview the facility failed to evaluate and categorize the buildings electrical systems by the use of a formal documented risk assessment procedure.

Chapter 4 of the 2012 edition of NFPA 99 Health Care facilities Code requires that facilities must evaluate specific building systems and categorize each system based on its potential impact to patient and caregiver if the system should fail.

-Chapter 4 Section 4.1 states building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.

-Chapter 4 Section 4.1.1 Category 1. States facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.

-Chapter 4 Section 4.1.2 Category 2. States facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code.

-Chapter 4 Section 4.1.3 Category 3. States facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code.

-Chapter 4 Section 4.1.4 Category 4. States facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code.

-Chapter 4 Section 4.2 Risk Assessment. States categories shall be determined by following and documenting a defined risk assessment procedure.

-Chapter 4 Section 4.3 Application. States the Category definitions in Chapter 4 shall apply to Chapters 5 through 11.

Findings Include:

A review of facility life safety documentation, conducted during the afternoon hours of 3/13/17, failed to indicate that a formal and documented risk assessment procedure by qualified personnel was conducted for the buildings electrical systems. When questioned the Director of Facilities & Environmental Services stated that he was unaware of the requirement.

As a result of the finding the facility failed to evaluate and identify the category of the building's electrical systems by the use of a risk assessment procedure and also failed to ensure that the electrical systems are designed to meet specific category requirements.

The findings were confirmed by the Director of Facilities & Environmental Services during the documentation review process.

Based on observations and documentation review the facility failed to ensure its Type 2 Essential Electrical System (EES) is in compliance with Chapter 6 "Electrical Systems" of the 2012 edition of NFPA 99 "Health Care Facilities Code".

-Chapter 6 Section 6.1.1 states this chapter shall apply to new health care facilities as specified in Section 1.3.

-Chapter 1 Administration Section 1.3.2 states construction and equipment requirements shall be applied only to new construction and new equipment, except as modified in individual chapters.

-Chapter 6 Section 6.3.2.2.10.2 states General care rooms (Category 2 Room) shall be served by a Type I or Type II EES.

-Chapter 6 Section 6.5.2.2.2 .1 (Type 2 EES) states the life safety and critical branch shall supply power for lighting, receptacles and equipment as follows:
(1) Illumination of means of egress in accordance with NFPA 101, Life safety Code
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life safety Code
(3) Alarm and alerting systems, including the following:
(a) Fire alarms
(b) Alarms required for systems used for the piping of non flammable medical gases as specified in Chapter 5
(4) Communication systems, where used for issuing instructions during emergency conditions
(5) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of a minimum of 5 ft candles
(6) Task illumination and select receptacles at the generator set location
(7) Elevator cab lighting, control, communications, and signal systems

-Chapter 6 Section 6.5.2.2.2.2 (Type 2 EES) states no function other than those listed in 6.5.2.2.2.1.(1) through (7), shall be connected to the life safety.

-Chapter 6 Section 6.5.2.2.3.1 (A) (Type 2 EES) states the equipment branch shall be installed and connected to the alternate power source such that equipment listed in 6.5.2.2.3.2 is automatically restored to operation at appropriate time-lag intervals following the restoration of the life safety and equipment branches to operation.
(B) The equipment branch arrangement shall also provide for the additional connection of equipment listed in 6.5.2.2.3.3.

-Chapter 6 Section 6.5.2.2.4.1* Separation from Other Circuits (Type 2 EES) requires that the life safety and equipment branches shall be kept entirely independent of all other wiring and equipment.

Findings Include:

While conducting an inspection of the facility's main electrical room during the afternoon hours of 3/13/17 observations revealed that the facility's Essential Electrical System is not equipped with a dedicated Life Safety Branch or a dedicated Equipment Branch as required for a Type 2 EES. In addition, a review of a construction document identified as: Drawing Number E5.4 Project Number 15042 "Panel Schedules" failed to identify any of the panels located in the main electrical room as Life Safety or Equipment branch panels.

When asked if the Life Safety or Equipment branch panels were located in another location, the facility's Director of Facilities & Environmental Services stated no. He further stated due to the fact that the generator provided emergency power to the entire building, upon loss of normal power, dedicated Life Safety and Equipment branches were not required.

As a result of the finding the facility is found to be non-compliant with the following sections of Chapter 6 Electrical Systems of the 2012 edition of NFPA 99 Health Care Facilities Code.
-Section 6.5.2.2.2.1
-Section 6.5.2.2.2.2
-Section 6.5.2.2.3.1 (A)
-Section 6.5.2.2.4.1

The findings were discussed with the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities & Environmental Services during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that the essential electrical system is monitored as required.

NFPA 99 section 6.4.1.1.17 states a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:

(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning

(2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in 6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

Section 6.4.1.1.17.1 states a remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel.

THE FINDINGS INCLUDE:

During the morning hours of 3/13/17 while reviewing the emergency electrical system, it was observed that the only remote annunciator panel is located in the main electrical room which is not attended on a regular basis.

As a result, the facility failed to comply with NFPA 99 section 6.4.1.1.17 requiring the annunciator panel to be located at a work site observable by personnel.

The findings were confirmed by the Facility's Chief Operating Officer, Director of Support Services and Director of Facilities during the exit conference.