HospitalInspections.org

Based on observations and confirmed by staff, the facility failed to ensure that buildings are properly separated. Section 19.1.1.4.1 states additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.
NFPA 80 section 1-5.1 states listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
NFPA 80 section 1-5.1 states listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

THE FINDINGS INCLUDE:

During the morning of 3/12/14 at approximately 11:30 A.M. while touring the ground floor level, it was observed that the buildings are not separated as required. (Note: Please refer to ID Tag K012 in Bldg. #01 for Building construction deficiency)
The designated 2-hour fire wall in the rear corridor was observed to have the following deficiencies:

1) The door leading into the kitchen is not equipped with a label to ensure it is classified as at least a 90-minute door. In addition, the door is not equipped with any self latching mechanism to ensure the door achieves positive latching.

2) The door leading into the staff bathroom is equipped with a 18" x 12" louver. As a result, the door has no fire resistance rating.

3) The three doors leading into the pharmacy are not equipped with labels to ensure the 90-minute fire resistance rating. Two of the doors are not equipped with any self closing mechanisms. The wired glass was removed in one of these doors and replaced with non-rated plexiglass.

4) According to the floor plans provided, the fire wall separates two small rooms used for housekeeping materials. When this area was observed, the fire door specified on the plans was not provided. The door has been removed and the rooms are now open to each other, as a result, the barrier is not intact as required.

5) The door leading into the 3rd floor medication room is not equipped with a self closing device.

6) Please refer to the deficiency noted under ID Prefix Tag K67 regarding improper building separation due to the lack of fire dampers.

These were acknowledged by the Administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that the building is of a conforming construction type. Section 19-1.6.2 requires buildings 4-stories in height to be of at least Type I (443), Type I (332) or Type II (222).

THE FINDINGS INCLUDE:

During the afternoon of 3/10/14 at approximately 3:30 P.M. it was observed that the building is of Type III (200) construction and is four (4) stories in height. This is due to the wood roof construction of the building being non-protected. The wood rafters, wood sheathing, and the various steel supports/beams are exposed in numerous locations throughout the entire occupied 4th floor level. This construction classification is not acceptable as outlined above.

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

Based on observations and confirmed by staff, the facility failed to ensure that stairwells/shafts are constructed as required. Section 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with 8.2.5. Section 8.2.5.2 states openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

THE FINDINGS INCLUDE:

During the afternoon hours of 3/11/14 at approximately 2:30 P.M. it was observed that the abandoned dumb waiter shaft is not sealed as required. When the shaft door on the 2nd floor was opened for viewing, an approximate 12" x 12" hole was observed in the shaft wall. Upon closer observation it was observed that the hole was created for the installation of electrical wiring which terminates at a corridor mounted electrical panel.

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

Based on observations and confirmed by staff, the facility failed to ensure that hazardous area doors are held open by approved devices. NFPA 101, Life Safety Code 2000 Edition, 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.
NFPA 72-1999 Edition, 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 afternoon hours of 3/11/14, while touring the facility at approximately 2:00 PM, observations revealed the door to the Medical Records Office which is located on the ground floor of building #02 was being held in the open position by an unapproved device. Due to the size and the contents the facilities Medical Records Office it is considered a hazardous area enclosure and shall be permitted to be held open only by an automatic release mechanism that is connected to a properly located smoke detection device.

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

Based on observations and confirmed by staff, the facility failed to ensure that stairwells are maintained as required. Section 4.5.7 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

THE FINDINGS INCLUDE:

During the morning hours of 3/12/14 at approximately 11:00 A.M. it was observed that the Center stairwell is not maintained as constructed. When the stairwell was checked for the structural integrity, it was observed that the bottom landing has been altered. The original door leading into the rear egress corridor was removed and sealed with a single layer of gypsum board. As a result, the stairwell no longer has the required fire resistance rating.

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

Based on observations and confirmed by staff, the facility failed to ensure stairwells are the minimum required width. Section 19.2.2.3 refers to chapter 7. Table 7.2.2.2.1 (b) states existing stairs must have a minimum clear width of 44" with projections of not more than 3-1/2" at or below handrail height. Table 7.2.2.2.1 (b) states the minimum headroom is 6'-8" in height. Section 7.2.2.3.3 states stair treads and landings shall be solid, without perforations, and free of projections or lips that could trip stair users.
Section 7.2.2.3.6 states there shall be no variation in excess of 3/16 in. (0.5 cm) in the depth of adjacent treads or in the height of adjacent risers, and the tolerance between the largest and smallest riser or between the largest and smallest tread shall not exceed 3/8 in. (1 cm) in any flight.

THE FINDINGS INCLUDE:

During the morning of 3/12/14 at approximately 10:30 A.M. while walking the interior of the South & Center stairwells, the following items were observed:

1) The South & Center stairwells are each 41" in clear width.
2) The South stairwell has heating radiators on each of the landings extending 10" from the wall.
3) The South stairwell has two locations where the headroom is reduced to approximately 6' in total height.
4) The South stairwell is equipped with a perforated landing and stairs at the lowest level before discharge.
5) The South stairwell has a 1-1/4" difference in risers at the discharge location.

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

Based on observation and confirmed by staff, the facility failed to ensure that sleeping suites are constructed/maintained as required. Section 19.2.5.6 states suites of sleeping rooms shall not exceed 5,000 ft2 (460 m2) in size.

THE FINDINGS INCLUDE:

During the morning hours of 3/11/14 at approximately 9:30 A.M. it was observed that the areas designated as the 2nd & 3rd floor North Suites exceed the allowable 5,000 square feet (sf) in total size. The suite sizes as provided by the facility are as follows:

3rd floor suite: 6,984 square feet in total size
2nd floor suite: 7,334 square feet in total size

Note: As stated under ID Prefix Tag K00, the facility provided a Categorical Waiver request for sleeping suites exceeding the allowable 5,000 square feet (sf) limit. The waiver request was denied at this time as the facility does not meet the requirements per the LSC 2012 Section 19.2.5.7.2.3(B). The facility is currently equipped with standard response sprinkler heads in the majority of these two locations. In addition, smoke detectors are not installed throughout the entire area as required. The hospital was originally designed/built utilizing corridors and rooms as opposed to suites. The two locations requiring oversized suite approval are equipped with doors to all the sleeping rooms, common spaces, offices, etc. These locations are not equipped with any smoke detectors as required for complete smoke detection.

The waiver for suite size increase is denied until the facility complies with one of the following requirements in each of the suites requesting waiver approval:

1) Complete smoke detection is provided with the existing standard response sprinkler heads throughout the entire area.

2) Quick response sprinkler heads are provided throughout the entire areas.

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

Based on observations and confirmed by staff, the facility failed to ensure compliance with section 7.9.2.3 which refers to NFPA 110 (Standards for Emergency Power Systems). NFPA 110 section 5-7.2 states adequate ventilation shall be provided to prevent temperatures or temperature rises in the EPS and related accessory equipment that exceed the recommendations of the manufacturer.
Section 5-7.3 states for the EPS equipment room, the ventilation or cooling equipment, or both, shall be sized so that the ambient temperature shall not exceed the EPS equipment manufacturer ' s criteria or allowable maximum temperatures.

THE FINDINGS INCLUDE:

During the morning hours of 3/12/14 at approximately 10:30 A.M. it was observed that the newly constructed emergency electrical room is not equipped with any means of ventilation. The temperature within the room was 120 degrees Fahrenheit at the time of observation, with an outside ambient air temperature of 37 degrees Fahrenheit. It was stated by facility personnel that the equipment could operate as designed in temperatures up to 105 degrees Fahrenheit. The current room temperature exceeds the allowable amount by 15 degrees Fahrenheit.

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

Based on observations, the facility failed to ensure that automatic sprinklers are installed throughout the premises. Section 19.3.5.1 states where required health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA 13, Section 5.1.1(1) requires sprinklers to be installed throughout the premises.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 3/11/14, at approximately 11:45 AM, revealed automatic sprinkler protection is not provided in the bathroom closets of two patient rooms (316 & 317)located in the 3rd floor Mother-Baby Suite.

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

Based on observations, the facility failed to ensure that automatic sprinklers are installed throughout the premises and in accordance with regulations.
1) NFPA 13-1999 Edition, Section 5.1.1(1) requires sprinklers to be installed throughout the premises.

2) 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".

3) 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 including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room."

THE FINDINGS INCLUDE:

1) Observations while touring the facility on the afternoon of 3/11/14, at approximately 3:30 P.M., revealed that automatic sprinkler protection is not provided in the following areas:

a) The non-rated glass enclosed exit/entrance vestibule located on the first floor adjacent to the North Stairway is lacking sprinkler protection.

b) The storage closet located in the third floor North Suite staff office is lacking sprinkler protection.

Note: The hospital defines itself as fully-sprinklered and claims the pertinent exceptions which are allowed under fully-sprinklered status.

2) Observations while touring the facility on the morning of 3/12/14, at approximately 10:30 A.M., revealed that the non-sprinklered main electrical room contained two (2) penetrations into the adjacent mechanical room. The penetrations approximately 14" x 14" and 12" x 36" originally housed exhaust and combustion air duct work for the facility's generator which has been removed from the room. (The facility installed a new generator located outside the building in January of 2014.)

3) Observations while touring the facility on the afternoon of 3/11/14, at approximately 4:00 P.M., revealed the following rooms in building #2 to contain a mixture of both quick response and standard response sprinkler heads: Exam Room # 4; Patient Room #'s 1-7. This deficiency includes the above locations but is not limited to same as there may be other areas within the hospital where the condition exists.

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

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. NFPA 101 LSC 2000 Edition Section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/11/14, at approximately 1:30 P.M., observations revealed the butterfly control valve labeled SP-2, located in the fire alarm control room, is not equipped with a supervisory attachment. The control valve has the ability to shut off the water supply to a portion of the facility's automatic sprinkler system and must be equipped with a supervisory device.

Note: The valve was in the open position and held in such by means of a padlock.

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

Based on observations and confirmed by staff, the facility failed to ensure that buildings are properly separated. Section 19.1.1.4.1 states additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.
NFPA 90A section 3.3.1.1 requires approved fire dampers to be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 3.3.1.2 requires approved fire dampers to be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions.

THE FINDINGS INCLUDE:

During the morning of 3/11/14 between the hours of 10:30 A.M. and 11:30 A.M. while touring the 2nd & 3rd floor levels, it was observed that the buildings are not separated as required. The following locations but not limited to were observed to have deficiencies regarding duct work:

1) There is a 6" round duct penetrating the 2-hour wall above the ceiling in the bathroom of room #318. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

2) There is a 6" x 6" duct penetrating the 2-hour wall above the ceiling located at 3rd floor nurse's station. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

3) There is a 14" x 10" duct penetrating the 2-hour wall above the ceiling located at 3rd floor nurse's station. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

4) There is a 14" x 10" duct penetrating the 2-hour wall above the ceiling located at 3rd floor rehabilitation office. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

5) There is a 12" x 4" duct penetrating the 2-hour wall above the ceiling in the closet of room #200. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

NOTE: As stated, the items listed above may not include all the locations where deficiencies exist. After observing these two floors, it was apparent that many of the duct penetrations are not equipped fire damper access panels. As a result, the ducts could not be checked for the presence of the required fire dampers.

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

Based on observations and confirmed by staff, the facility failed to ensure that oxygen storage rooms containing cylinders are properly secured. NFPA 99 section 4-3.1.1.2 states the following:
Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
4) 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.

THE FINDINGS INCLUDE:

During the afternoon hours of 3/11/14 at approximately 4:30 P.M. it was observed that the oxygen storage room is not equipped with any type of ventilation system. The room which contains approximately twenty "H-size cylinders" (250 cubic feet each) and twenty "E-size cylinders" (25 cubic feet each) is required to be vented to the outside.

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

Based on record review the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by NFPA #25-1998 Edition and installed in accordance with NFPA #13-1999 Edition.

A) NFPA #25 Section 1.8 requires records of inspections, tests and maintenance of the system and components be kept and made available to the authority having jurisdiction. Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results and the date.
B) NFPA #25 Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly.
C) NFPA #25 Section 2-3.3 states waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head.
D) NFPA #13, Section 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

1) A review of the quarterly automatic sprinkler system reports for 2013, made available at time of survey, revealed the following:

A) There is no documentation to substantiate the conducting of quarterly flow alarm testing by means of the inspector's test valve.

B) There is no documentation to substantiate that the wet system pressure gages (both supply and system sides) are being inspected monthly as required.

2) An inspection of the facility's automatic sprinkler system on the afternoon of 3/11/14, at approximately 2:45 P.M., revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valve of the system, however they are not installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

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

A. Based on record review and confirmed by interview with the physical plant director, the facility failed to ensure that a 30 minute discharge test is performed on the fire alarm system backup batteries annually. N.F.P.A.72 National Fire Alarm Code 1999 Edition section 3-2.4.1 states non-required protected premises systems shall meet the requirements of this code. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

-A review of the facilities semi-annual fire alarm system inspection reports made available on 3/11/14 failed to reveal whether a 30 minute annual battery discharge test had been conducted in 2013. The reports did document the conducting of semi-annual load voltage tests.


B. Based on record review the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by NFPA #25-1998 Edition and installed in accordance with NFPA #13-1999 Edition.

1) NFPA #25 Section 1.8 requires records of inspections, tests and maintenance of the system and components be kept and made available to the authority having jurisdiction. Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results and the date.
2) NFPA #25 Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly.
3) NFPA #25 Section 2-3.3 states waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head.
4) NFPA #13, Section 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

1) A review of the quarterly automatic sprinkler system reports for 2013, made available at time of survey, revealed the following:

A) There is no documentation to substantiate the conducting of quarterly flow alarm testing by means of the inspector's test valve.

B) There is no documentation to substantiate that the wet system pressure gages (both supply and system sides) are being inspected monthly as required.

2) An inspection of the facility's automatic sprinkler system on the afternoon of 3/11/14, at approximately 2:45 P.M., revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valve of the system, however they are not installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

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

Based on observations and confirmed by staff, the facility failed to ensure that buildings are properly separated. Section 19.1.1.4.1 states additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.
NFPA 80 section 1-5.1 states listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
NFPA 80 section 1-5.1 states listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

THE FINDINGS INCLUDE:

During the morning of 3/12/14 at approximately 11:30 A.M. while touring the ground floor level, it was observed that the buildings are not separated as required. (Note: Please refer to ID Tag K012 in Bldg. #01 for Building construction deficiency)
The designated 2-hour fire wall in the rear corridor was observed to have the following deficiencies:

1) The door leading into the kitchen is not equipped with a label to ensure it is classified as at least a 90-minute door. In addition, the door is not equipped with any self latching mechanism to ensure the door achieves positive latching.

2) The door leading into the staff bathroom is equipped with a 18" x 12" louver. As a result, the door has no fire resistance rating.

3) The three doors leading into the pharmacy are not equipped with labels to ensure the 90-minute fire resistance rating. Two of the doors are not equipped with any self closing mechanisms. The wired glass was removed in one of these doors and replaced with non-rated plexiglass.

4) According to the floor plans provided, the fire wall separates two small rooms used for housekeeping materials. When this area was observed, the fire door specified on the plans was not provided. The door has been removed and the rooms are now open to each other, as a result, the barrier is not intact as required.

5) The door leading into the 3rd floor medication room is not equipped with a self closing device.

6) Please refer to the deficiency noted under ID Prefix Tag K67 regarding improper building separation due to the lack of fire dampers.

These were acknowledged by the Administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that the building is of a conforming construction type. Section 19-1.6.2 requires buildings 4-stories in height to be of at least Type I (443), Type I (332) or Type II (222).

THE FINDINGS INCLUDE:

During the afternoon of 3/10/14 at approximately 3:30 P.M. it was observed that the building is of Type III (200) construction and is four (4) stories in height. This is due to the wood roof construction of the building being non-protected. The wood rafters, wood sheathing, and the various steel supports/beams are exposed in numerous locations throughout the entire occupied 4th floor level. This construction classification is not acceptable as outlined above.

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

Based on observations and confirmed by staff, the facility failed to ensure that stairwells/shafts are constructed as required. Section 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with 8.2.5. Section 8.2.5.2 states openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

THE FINDINGS INCLUDE:

During the afternoon hours of 3/11/14 at approximately 2:30 P.M. it was observed that the abandoned dumb waiter shaft is not sealed as required. When the shaft door on the 2nd floor was opened for viewing, an approximate 12" x 12" hole was observed in the shaft wall. Upon closer observation it was observed that the hole was created for the installation of electrical wiring which terminates at a corridor mounted electrical panel.

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

Based on observations and confirmed by staff, the facility failed to ensure that hazardous area doors are held open by approved devices. NFPA 101, Life Safety Code 2000 Edition, 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.
NFPA 72-1999 Edition, 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 afternoon hours of 3/11/14, while touring the facility at approximately 2:00 PM, observations revealed the door to the Medical Records Office which is located on the ground floor of building #02 was being held in the open position by an unapproved device. Due to the size and the contents the facilities Medical Records Office it is considered a hazardous area enclosure and shall be permitted to be held open only by an automatic release mechanism that is connected to a properly located smoke detection device.

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

Based on observations and confirmed by staff, the facility failed to ensure that stairwells are maintained as required. Section 4.5.7 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

THE FINDINGS INCLUDE:

During the morning hours of 3/12/14 at approximately 11:00 A.M. it was observed that the Center stairwell is not maintained as constructed. When the stairwell was checked for the structural integrity, it was observed that the bottom landing has been altered. The original door leading into the rear egress corridor was removed and sealed with a single layer of gypsum board. As a result, the stairwell no longer has the required fire resistance rating.

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

Based on observations and confirmed by staff, the facility failed to ensure stairwells are the minimum required width. Section 19.2.2.3 refers to chapter 7. Table 7.2.2.2.1 (b) states existing stairs must have a minimum clear width of 44" with projections of not more than 3-1/2" at or below handrail height. Table 7.2.2.2.1 (b) states the minimum headroom is 6'-8" in height. Section 7.2.2.3.3 states stair treads and landings shall be solid, without perforations, and free of projections or lips that could trip stair users.
Section 7.2.2.3.6 states there shall be no variation in excess of 3/16 in. (0.5 cm) in the depth of adjacent treads or in the height of adjacent risers, and the tolerance between the largest and smallest riser or between the largest and smallest tread shall not exceed 3/8 in. (1 cm) in any flight.

THE FINDINGS INCLUDE:

During the morning of 3/12/14 at approximately 10:30 A.M. while walking the interior of the South & Center stairwells, the following items were observed:

1) The South & Center stairwells are each 41" in clear width.
2) The South stairwell has heating radiators on each of the landings extending 10" from the wall.
3) The South stairwell has two locations where the headroom is reduced to approximately 6' in total height.
4) The South stairwell is equipped with a perforated landing and stairs at the lowest level before discharge.
5) The South stairwell has a 1-1/4" difference in risers at the discharge location.

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

Based on observation and confirmed by staff, the facility failed to ensure that sleeping suites are constructed/maintained as required. Section 19.2.5.6 states suites of sleeping rooms shall not exceed 5,000 ft2 (460 m2) in size.

THE FINDINGS INCLUDE:

During the morning hours of 3/11/14 at approximately 9:30 A.M. it was observed that the areas designated as the 2nd & 3rd floor North Suites exceed the allowable 5,000 square feet (sf) in total size. The suite sizes as provided by the facility are as follows:

3rd floor suite: 6,984 square feet in total size
2nd floor suite: 7,334 square feet in total size

Note: As stated under ID Prefix Tag K00, the facility provided a Categorical Waiver request for sleeping suites exceeding the allowable 5,000 square feet (sf) limit. The waiver request was denied at this time as the facility does not meet the requirements per the LSC 2012 Section 19.2.5.7.2.3(B). The facility is currently equipped with standard response sprinkler heads in the majority of these two locations. In addition, smoke detectors are not installed throughout the entire area as required. The hospital was originally designed/built utilizing corridors and rooms as opposed to suites. The two locations requiring oversized suite approval are equipped with doors to all the sleeping rooms, common spaces, offices, etc. These locations are not equipped with any smoke detectors as required for complete smoke detection.

The waiver for suite size increase is denied until the facility complies with one of the following requirements in each of the suites requesting waiver approval:

1) Complete smoke detection is provided with the existing standard response sprinkler heads throughout the entire area.

2) Quick response sprinkler heads are provided throughout the entire areas.

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

Based on observations and confirmed by staff, the facility failed to ensure compliance with section 7.9.2.3 which refers to NFPA 110 (Standards for Emergency Power Systems). NFPA 110 section 5-7.2 states adequate ventilation shall be provided to prevent temperatures or temperature rises in the EPS and related accessory equipment that exceed the recommendations of the manufacturer.
Section 5-7.3 states for the EPS equipment room, the ventilation or cooling equipment, or both, shall be sized so that the ambient temperature shall not exceed the EPS equipment manufacturer ' s criteria or allowable maximum temperatures.

THE FINDINGS INCLUDE:

During the morning hours of 3/12/14 at approximately 10:30 A.M. it was observed that the newly constructed emergency electrical room is not equipped with any means of ventilation. The temperature within the room was 120 degrees Fahrenheit at the time of observation, with an outside ambient air temperature of 37 degrees Fahrenheit. It was stated by facility personnel that the equipment could operate as designed in temperatures up to 105 degrees Fahrenheit. The current room temperature exceeds the allowable amount by 15 degrees Fahrenheit.

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

Based on record review and confirmed by interview with the physical plant director, the facility failed to ensure that a 30 minute discharge test is performed on the fire alarm system backup batteries annually. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

-A review of the facilities semi-annual fire alarm system inspection reports made available on 3/11/14 failed to reveal whether a 30 minute annual battery discharge test had been conducted in 2013. The reports did document the conducting of semi-annual load voltage tests.

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

Based on observations, the facility failed to ensure that automatic sprinklers are installed throughout the premises. Section 19.3.5.1 states where required health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA 13, Section 5.1.1(1) requires sprinklers to be installed throughout the premises.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 3/11/14, at approximately 11:45 AM, revealed automatic sprinkler protection is not provided in the bathroom closets of two patient rooms (316 & 317)located in the 3rd floor Mother-Baby Suite.

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

Based on observations, the facility failed to ensure that automatic sprinklers are installed throughout the premises and in accordance with regulations.
1) NFPA 13-1999 Edition, Section 5.1.1(1) requires sprinklers to be installed throughout the premises.

2) 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".

3) 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 including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room."

THE FINDINGS INCLUDE:

1) Observations while touring the facility on the afternoon of 3/11/14, at approximately 3:30 P.M., revealed that automatic sprinkler protection is not provided in the following areas:

a) The non-rated glass enclosed exit/entrance vestibule located on the first floor adjacent to the North Stairway is lacking sprinkler protection.

b) The storage closet located in the third floor North Suite staff office is lacking sprinkler protection.

Note: The hospital defines itself as fully-sprinklered and claims the pertinent exceptions which are allowed under fully-sprinklered status.

2) Observations while touring the facility on the morning of 3/12/14, at approximately 10:30 A.M., revealed that the non-sprinklered main electrical room contained two (2) penetrations into the adjacent mechanical room. The penetrations approximately 14" x 14" and 12" x 36" originally housed exhaust and combustion air duct work for the facility's generator which has been removed from the room. (The facility installed a new generator located outside the building in January of 2014.)

3) Observations while touring the facility on the afternoon of 3/11/14, at approximately 4:00 P.M., revealed the following rooms in building #2 to contain a mixture of both quick response and standard response sprinkler heads: Exam Room # 4; Patient Room #'s 1-7. This deficiency includes the above locations but is not limited to same as there may be other areas within the hospital where the condition exists.

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

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. NFPA 101 LSC 2000 Edition Section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/11/14, at approximately 1:30 P.M., observations revealed the butterfly control valve labeled SP-2, located in the fire alarm control room, is not equipped with a supervisory attachment. The control valve has the ability to shut off the water supply to a portion of the facility's automatic sprinkler system and must be equipped with a supervisory device.

Note: The valve was in the open position and held in such by means of a padlock.

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

Based on record review the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by NFPA #25-1998 Edition and installed in accordance with NFPA #13-1999 Edition.

1) NFPA #25 Section 1.8 requires records of inspections, tests and maintenance of the system and components be kept and made available to the authority having jurisdiction. Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results and the date.
2) NFPA #25 Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly.
3) NFPA #25 Section 2-3.3 states waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head.
4) NFPA #13, Section 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

1) A review of the quarterly automatic sprinkler system reports for 2013, made available at time of survey, revealed the following:

A) There is no documentation to substantiate the conducting of quarterly flow alarm testing by means of the inspector's test valve.

B) There is no documentation to substantiate that the wet system pressure gages (both supply and system sides) are being inspected monthly as required.

2) An inspection of the facility's automatic sprinkler system on the afternoon of 3/11/14, at approximately 2:45 P.M., revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valve of the system, however they are not installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

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

Based on observations and confirmed by staff, the facility failed to ensure that buildings are properly separated. Section 19.1.1.4.1 states additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.
NFPA 90A section 3.3.1.1 requires approved fire dampers to be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 3.3.1.2 requires approved fire dampers to be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions.

THE FINDINGS INCLUDE:

During the morning of 3/11/14 between the hours of 10:30 A.M. and 11:30 A.M. while touring the 2nd & 3rd floor levels, it was observed that the buildings are not separated as required. The following locations but not limited to were observed to have deficiencies regarding duct work:

1) There is a 6" round duct penetrating the 2-hour wall above the ceiling in the bathroom of room #318. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

2) There is a 6" x 6" duct penetrating the 2-hour wall above the ceiling located at 3rd floor nurse's station. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

3) There is a 14" x 10" duct penetrating the 2-hour wall above the ceiling located at 3rd floor nurse's station. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

4) There is a 14" x 10" duct penetrating the 2-hour wall above the ceiling located at 3rd floor rehabilitation office. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

5) There is a 12" x 4" duct penetrating the 2-hour wall above the ceiling in the closet of room #200. There is no fire damper access panel to ensure that the duct is equipped with the required fire damper.

NOTE: As stated, the items listed above may not include all the locations where deficiencies exist. After observing these two floors, it was apparent that many of the duct penetrations are not equipped fire damper access panels. As a result, the ducts could not be checked for the presence of the required fire dampers.

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

Based on observations and confirmed by staff, the facility failed to ensure that oxygen storage rooms containing cylinders are properly secured. NFPA 99 section 4-3.1.1.2 states the following:
Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
4) 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.

THE FINDINGS INCLUDE:

During the afternoon hours of 3/11/14 at approximately 4:30 P.M. it was observed that the oxygen storage room is not equipped with any type of ventilation system. The room which contains approximately twenty "H-size cylinders" (250 cubic feet each) and twenty "E-size cylinders" (25 cubic feet each) is required to be vented to the outside.

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

Based on record review the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by NFPA #25-1998 Edition and installed in accordance with NFPA #13-1999 Edition.

A) NFPA #25 Section 1.8 requires records of inspections, tests and maintenance of the system and components be kept and made available to the authority having jurisdiction. Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results and the date.
B) NFPA #25 Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly.
C) NFPA #25 Section 2-3.3 states waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head.
D) NFPA #13, Section 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

1) A review of the quarterly automatic sprinkler system reports for 2013, made available at time of survey, revealed the following:

A) There is no documentation to substantiate the conducting of quarterly flow alarm testing by means of the inspector's test valve.

B) There is no documentation to substantiate that the wet system pressure gages (both supply and system sides) are being inspected monthly as required.

2) An inspection of the facility's automatic sprinkler system on the afternoon of 3/11/14, at approximately 2:45 P.M., revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valve of the system, however they are not installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

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

A. Based on record review and confirmed by interview with the physical plant director, the facility failed to ensure that a 30 minute discharge test is performed on the fire alarm system backup batteries annually. N.F.P.A.72 National Fire Alarm Code 1999 Edition section 3-2.4.1 states non-required protected premises systems shall meet the requirements of this code. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.5.2.2 requires permanent records of all inspections, testing, and maintenance of the fire alarm system be provided including detailed information as to the results. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually. Annually is defined as periods of approximately 12 months.

THE FINDINGS INCLUDE:

-A review of the facilities semi-annual fire alarm system inspection reports made available on 3/11/14 failed to reveal whether a 30 minute annual battery discharge test had been conducted in 2013. The reports did document the conducting of semi-annual load voltage tests.


B. Based on record review the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by NFPA #25-1998 Edition and installed in accordance with NFPA #13-1999 Edition.

1) NFPA #25 Section 1.8 requires records of inspections, tests and maintenance of the system and components be kept and made available to the authority having jurisdiction. Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results and the date.
2) NFPA #25 Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly.
3) NFPA #25 Section 2-3.3 states waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head.
4) NFPA #13, Section 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

THE FINDINGS INCLUDE:

1) A review of the quarterly automatic sprinkler system reports for 2013, made available at time of survey, revealed the following:

A) There is no documentation to substantiate the conducting of quarterly flow alarm testing by means of the inspector's test valve.

B) There is no documentation to substantiate that the wet system pressure gages (both supply and system sides) are being inspected monthly as required.

2) An inspection of the facility's automatic sprinkler system on the afternoon of 3/11/14, at approximately 2:45 P.M., revealed that a pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valve of the system, however they are not installed on the supply side of the back-flow preventer. Back-flow preventers allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventers.

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