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Based on observations the facility failed to ensure that the building is of a conforming construction type. NFPA #101 "Life Safety Code" Chapter 19 "Existing Health Care Occupancies" 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). If the building is fully sprinklered it may be of Type II (111) construction.

Findings Include:

A record review of facility construction documentation and observations made while conducting the life safety survey during the morning and afternoon hours of 7/07-08/15 revealed the following.

1. Construction documents indicate that the original hospital building was constructed circa 1949 with additional space added circa 1967. Observations and construction information also reveal the original building and the subsequent 1967 addition to be of Type I (332) construction.

2. A three story addition was built on top of a rear portion of the original building sometime between the construction of the original building and the 1967 addition. There was no documentation made available at time of survey to substantiate date of construction or construction type. The three story addition was built on top of a rear portion of the original building's ground level. Observations made above portions of suspended ceilings located in various areas of the addition revealed the existence of unprotected steel girders and beams, unprotected steel bar joists and unprotected (untented) recessed lighting fixtures. With the absence of documentation indicating otherwise, observations reveal the addition's construction type as Type II (000).
Note: There is no fire-resistive separation between the Type I (332) and Type II (000) construction.

3. Located at the end of the first floor West Wing corridor is an approximate twelve (12) by twenty-eight (28) foot single story bump-out addition labeled "Chapel". The addition is built on top of the roof of the ground level morgue. There was no documentation made available at time of survey to substantiate date of construction or construction type. Observations revealed components of the additions structure to be other than fire-resistive in nature.
Note: There is no fire-resistive separation between the "Chapel" addition and the Type I (332) construction.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19-1.6.2 of the 2000 edition of NFPA #101 "Life Safety Code".

The findings were confirmed by the Director of Plant Services and the Chief Operating Officer during the conducting of the exit conference.

Based on observations, the facility failed to ensure that all use areas are separated from corridors as required. The 2000 edition of NFPA #101 "Life Safety Code" Chapter 19 Section 19.3.6.1 states corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)

Exception No. 6: 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 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.

Findings Include:

Observations while conducting the facility tour during the afternoon hours of 7/07/15 and 7/08/15 revealed the following.

1. The area designated as the Radiology Patient changing room, located on the third floor, is considered a treatment/patient care area and as such does not meet Exception No. 6 of Chapter 19 Section 19.3.6.1. The changing room must be separated from the corridor and its opening protected by a door which complies with the regulations included in Chapter 19 Section 19.3.6.3 "Corridor Doors".

2. The Rehabilitation Reception office and the Main Lobby Reception office, both located on the first floor, are not protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.

The corridors onto which the spaces open are protected in accordance with (a) of Exception No. 6 and the rooms meet the criteria of (b) and (c) of Exception No. 6. However to meet compliancy with the exception to Chapter 19 Section 19.3.6.1 smoke detectors must be installed within the
confines of the rooms.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19.3.6.1.

The findings were confirmed by the Director of Plant Services and the Chief Operating Officer during the conducting of the exit conference.

Based on observations, the facility failed to ensure that hazardous areas are enclosed as required. NFPA #101 "Life Safety Code" 2000 Edition Chapter 19 Section 19.3.2.1 "Hazardous Areas" requires doors protecting hazardous areas to be self-closing or automatic-closing.

Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings Include:

Observations while touring the facility on the afternoon of 7/08/15 revealed that the entrance door to the Central Supply storage area and the entrance door to the Medical Records storage office are not equipped with self-closing devices. Both rooms are greater than fifty (50) square feet in size and house greater than normal quantities of combustible materials and must be protected by self or automatic closing doors.

As a result of the findings the facility is found to be non-compliant with Chapter 19 Section 19.3.2.1. of NFPA #101 "Life Safety Code".

The finding was confirmed by the Director of Plant Services and the Chief Operating Officer during the conducting of the exit conference.

Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7 and means of egress components in accordance with Section 7-2. Section 7.2.2.3.3 requires that stair treads and landings shall be solid, without perforations, and free of projections or lips that could trip stair users. If not vertical, risers shall be permitted to slope under the tread at an angle not to exceed 30 degrees from vertical; however, the permitted projection of the nosing shall not exceed 11/2 in. (3.8 cm).

THE FINDINGS INCLUDE:

Observations while touring the facility in the morning of 7/8/15 revealed means of egress from the West wing from the first floor leads to an outside stair constructed of metal. The landing and stair treads are not solid, they are constructed with open grated metal. In addition, the stairs do not have risers.

As a result of the findings the facility is found to be non-compliant with Section 7.2.2.3.3.

Based on record review and confirmed by staff interview, the facility failed to conduct fire drills as required. NFPA 101 Life Safety Code Chapter 19 Section 19.7.1.2 states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

THE FINDINGS INCLUDE:

A review of the facility's last 12 months fire drill reports, conducted on the morning of 7/7/15, revealed the lack of documentation to substantiate fire drills being held on the following:

- the 1st quarter of 2015 on the 11-7 shift,
- the 4th quarter of 2014 on the 11-7 shift,
- the 1st quarter of 2015 on the 3-11 shift, and
- the 3rd quarter of 2014 on the 3-11 shift.

As a result of the findings the facility is found to be non-compliant with Section 19.7.1.2.

This was confirmed by the Director of Maintenance and reviewed with the Director of Maintenance and Administrator at the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. NFPA 101 section 19.3.5.1 states where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 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:

Observations made on the morning of 7/7/15, while conducting the facility tour, revealed the presence of the following non-supervised automatic sprinkler system control valves.

1. The two back flow system OS&Y control valves located in the facility's main boiler room.

2. The butterfly control valve located at the main sprinkler riser below the system flow valve.

As a result of the findings the facility is found to be non-compliant with NFPA 101 section 19.3.5.1.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff the facility failed to ensure that an accurate municipal water supply pressure could be monitored. The 1999 edition of NFPA #13 "Standard for the Installations of Sprinkler Systems" Chapter 4 Section 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

Findings Include:

Observations while touring the facility on the afternoon of 7/07/15, at approximately 2:00 PM, revealed that a pressure gauge is not installed on the supply side of the municipal backflow 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. A pressure gauge must be installed on the supply side of the back-flow preventer in order to accurately monitor the municipal water supply pressure.

As a result of the finding the facility is found to be non-compliant with section 4.7.7 of NFPA #13.

The finding was confirmed by the Director of Plant Services and Chief Operating Officer during the exit conference.

Based on observations the facility failed to ensure that the building is of a conforming construction type. NFPA #101 "Life Safety Code" Chapter 19 "Existing Health Care Occupancies" 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). If the building is fully sprinklered it may be of Type II (111) construction.

Findings Include:

A record review of facility construction documentation and observations made while conducting the life safety survey during the morning and afternoon hours of 7/07-08/15 revealed the following.

1. Construction documents indicate that the original hospital building was constructed circa 1949 with additional space added circa 1967. Observations and construction information also reveal the original building and the subsequent 1967 addition to be of Type I (332) construction.

2. A three story addition was built on top of a rear portion of the original building sometime between the construction of the original building and the 1967 addition. There was no documentation made available at time of survey to substantiate date of construction or construction type. The three story addition was built on top of a rear portion of the original building's ground level. Observations made above portions of suspended ceilings located in various areas of the addition revealed the existence of unprotected steel girders and beams, unprotected steel bar joists and unprotected (untented) recessed lighting fixtures. With the absence of documentation indicating otherwise, observations reveal the addition's construction type as Type II (000).
Note: There is no fire-resistive separation between the Type I (332) and Type II (000) construction.

3. Located at the end of the first floor West Wing corridor is an approximate twelve (12) by twenty-eight (28) foot single story bump-out addition labeled "Chapel". The addition is built on top of the roof of the ground level morgue. There was no documentation made available at time of survey to substantiate date of construction or construction type. Observations revealed components of the additions structure to be other than fire-resistive in nature.
Note: There is no fire-resistive separation between the "Chapel" addition and the Type I (332) construction.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19-1.6.2 of the 2000 edition of NFPA #101 "Life Safety Code".

The findings were confirmed by the Director of Plant Services and the Chief Operating Officer during the conducting of the exit conference.

Based on observations, the facility failed to ensure that all use areas are separated from corridors as required. The 2000 edition of NFPA #101 "Life Safety Code" Chapter 19 Section 19.3.6.1 states corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)

Exception No. 6: 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 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.

Findings Include:

Observations while conducting the facility tour during the afternoon hours of 7/07/15 and 7/08/15 revealed the following.

1. The area designated as the Radiology Patient changing room, located on the third floor, is considered a treatment/patient care area and as such does not meet Exception No. 6 of Chapter 19 Section 19.3.6.1. The changing room must be separated from the corridor and its opening protected by a door which complies with the regulations included in Chapter 19 Section 19.3.6.3 "Corridor Doors".

2. The Rehabilitation Reception office and the Main Lobby Reception office, both located on the first floor, are not protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.

The corridors onto which the spaces open are protected in accordance with (a) of Exception No. 6 and the rooms meet the criteria of (b) and (c) of Exception No. 6. However to meet compliancy with the exception to Chapter 19 Section 19.3.6.1 smoke detectors must be installed within the
confines of the rooms.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19.3.6.1.

The findings were confirmed by the Director of Plant Services and the Chief Operating Officer during the conducting of the exit conference.

Based on observations, the facility failed to ensure that hazardous areas are enclosed as required. NFPA #101 "Life Safety Code" 2000 Edition Chapter 19 Section 19.3.2.1 "Hazardous Areas" requires doors protecting hazardous areas to be self-closing or automatic-closing.

Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings Include:

Observations while touring the facility on the afternoon of 7/08/15 revealed that the entrance door to the Central Supply storage area and the entrance door to the Medical Records storage office are not equipped with self-closing devices. Both rooms are greater than fifty (50) square feet in size and house greater than normal quantities of combustible materials and must be protected by self or automatic closing doors.

As a result of the findings the facility is found to be non-compliant with Chapter 19 Section 19.3.2.1. of NFPA #101 "Life Safety Code".

The finding was confirmed by the Director of Plant Services and the Chief Operating Officer during the conducting of the exit conference.

Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7 and means of egress components in accordance with Section 7-2. Section 7.2.2.3.3 requires that stair treads and landings shall be solid, without perforations, and free of projections or lips that could trip stair users. If not vertical, risers shall be permitted to slope under the tread at an angle not to exceed 30 degrees from vertical; however, the permitted projection of the nosing shall not exceed 11/2 in. (3.8 cm).

THE FINDINGS INCLUDE:

Observations while touring the facility in the morning of 7/8/15 revealed means of egress from the West wing from the first floor leads to an outside stair constructed of metal. The landing and stair treads are not solid, they are constructed with open grated metal. In addition, the stairs do not have risers.

As a result of the findings the facility is found to be non-compliant with Section 7.2.2.3.3.

Based on record review and confirmed by staff interview, the facility failed to conduct fire drills as required. NFPA 101 Life Safety Code Chapter 19 Section 19.7.1.2 states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

THE FINDINGS INCLUDE:

A review of the facility's last 12 months fire drill reports, conducted on the morning of 7/7/15, revealed the lack of documentation to substantiate fire drills being held on the following:

- the 1st quarter of 2015 on the 11-7 shift,
- the 4th quarter of 2014 on the 11-7 shift,
- the 1st quarter of 2015 on the 3-11 shift, and
- the 3rd quarter of 2014 on the 3-11 shift.

As a result of the findings the facility is found to be non-compliant with Section 19.7.1.2.

This was confirmed by the Director of Maintenance and reviewed with the Director of Maintenance and Administrator at the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. NFPA 101 section 19.3.5.1 states where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 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:

Observations made on the morning of 7/7/15, while conducting the facility tour, revealed the presence of the following non-supervised automatic sprinkler system control valves.

1. The two back flow system OS&Y control valves located in the facility's main boiler room.

2. The butterfly control valve located at the main sprinkler riser below the system flow valve.

As a result of the findings the facility is found to be non-compliant with NFPA 101 section 19.3.5.1.

This was acknowledged by facility personnel during the tour and by the Director of Engineering during the exit interview.

Based on observations and confirmed by staff the facility failed to ensure that an accurate municipal water supply pressure could be monitored. The 1999 edition of NFPA #13 "Standard for the Installations of Sprinkler Systems" Chapter 4 Section 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.

Findings Include:

Observations while touring the facility on the afternoon of 7/07/15, at approximately 2:00 PM, revealed that a pressure gauge is not installed on the supply side of the municipal backflow 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. A pressure gauge must be installed on the supply side of the back-flow preventer in order to accurately monitor the municipal water supply pressure.

As a result of the finding the facility is found to be non-compliant with section 4.7.7 of NFPA #13.

The finding was confirmed by the Director of Plant Services and Chief Operating Officer during the exit conference.