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Based on observations, review of architectural drawings, and staff interviews, the facility's two hour fire wall between this building and a non-conforming business occupancy building lacked a two hour fire resistance rating. The non-conforming building failed to maintain the sprinkler heads, fire and smoke barriers, and required smoke detector locations. This could potentially affect all patients in the facility. The census on the first day of survey was 111 patients.

Findings include:

On 08/01/16 between 12:36 PM and 2:31 PM, and on 08/02/16 between 9:30 AM and 11:24 AM, a tour was conducted with Staff M and Staff N of the ground floor. This tour revealed the two hour fire rated barrier between this facility and the business occupancy was not maintained and lacked a two hour fire resistance rating as follows:

The fire barrier located between the facility's common corridor and the Lab/Clinic/Admissions area was observed with penetrations.

On the healthcare side of the corridor:
*A chiller and hot water pipes (two six inch pipes) had a whitish gray colored insulation type material around the pipes in the annular opening around the pipes;
*A four inch and six inch opening were observed in the drywall outside clinic room 1360.1;
*Over the 1360.1 door a three inch diameter conduit was open around wires inside the conduit.

On the Treatment Mall side of the fire barrier:
*Inside the Lab area a one inch opening around a cable and a gap in the one layer of drywall over the clock.

Staff M and Staff N were unsure how the fire barrier was constructed as the drywall was observed with brown colored backing, and the number of drywall layers could not be confirmed;

*Over the exit door to the healthcare corridor by the double elevators, a concrete block wall was observed approximately eight to 10 feet in height. This block was open at the top of the concrete wall approximately 16 to 20 feet in width. A three inch conduit, a half inch conduit, and two three quarter inch metal conduits were observed open and unsealed in this concrete wall.

The fire barrier located between the double elevators and open courtyard was observed with penetrations:
*Over the fire doors on the Treatment Mall side observed were one three quarter inch diameter conduit open around wires inside the conduit, and a two foot wide by two inch high opening at the top in which silver covered insulation was inserted.

The fire barrier located near C2 Unit and the entrance to the Treatment Mall (between two courtyards) was observed with penetrations as follows:
*On the C2 unit side the wall was observed with a two inch opening to the left side when facing the fire barrier doors;
*The Treatment Mall side of the fire barrier was observed with silver covered insulation which was in contact with a large portion of the fire barrier surface, disallowing visualization of the entire fire barrier wall. The top portion of the fire barrier was observed with an approximately 16 foot wide by eight to 12 inches high openings between the barrier and the corrugated metal decking.

Staff N was unable to confirm the fire resistance rating of the barrier on tour. A review of architectural drawings at the time of tour revealed this fire rated barrier had a two hour fire resistance rating.

All penetrations and observations of the fire barriers, and architectural drawings, were confirmed with Staff M and Staff N during tour.

Based on observation and interview, the facility failed to ensure all corridor openings had doors where required, and all corridor doors closed with their latching hardware latching. This had the potential to affect all patients in the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

On 08/01/16 at 2:00 PM, a tour with Staff M and Staff N and observations of the B2 in-patient unit revealed the patient room B220 lacked a corridor door at the entrance into the room. A female patient was observed inside the room at the time of observation. The corridor doorframe was observed with a vinyl shower curtain hanging at the door. Staff M stated the patient tore the door up and the facility ordered a door a couple of days ago; however, the door had not been delivered.

On 08/02/16 at 9:56 AM a tour was conducted of the lower level with Staff Q and R.

On 08/02/16 at 1:50 PM observation of the corridor door to patient room 118 revealed it did not completely close and latch because the door would stick to the top part of the frame.

On 08/02/16 at 1:50 PM in an interview, Staff Q and R confirmed the observation.

On 08/03/16 at 9:15 AM a tour was taken of the facility with Staff Q.

On 08/03/16 at 10:23 AM the corridor door to patient room c118 did not close as it would become stuck on the frame making it unable to close and latch.

On 08/03/16 at 10:23 AM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 2:17 PM the corridor door to patient room d130 was observed to stick on the frame preventing it from closing and latching.

On 08/03/16 at 2:17 PM in an interview, Staff Q confirmed the finding.




03245

Based on observation and interview, the facility failed to ensure compliance with 7.10.8.1. This had the potential to affect all patients in the facility. The facility had a census of 111 patients.

Findings include:

On 08/01/16 at 1:32 PM, a tour was conducted with Staff M and Staff N.

On the ground level of the Administrative building, an open stairwell was observed near the entrance of the in-patient building. The stairwell was observed with an illuminated exit sign at the top of the stairwell. A locked metal door near the top of the stairs and was observed with a sign over the door that contained the following words: "Do Not Enter When Lit ".

When questioned as to the path of egress in this area, Staff M stated the path of egress was through the metal door leading into the in-patient unit.

An egress corridor was observed in the Administrative building on the ground level by the police department. This corridor was approximately 25 feet in length and was located between the in-patient units and the Administration building lobby/atrium area. Both ends of this corridor were observed with latching doors. An exit sign was observed on the outside of the door closest to the in-patient unit. Upon entering the corridor, two unlocked public restrooms were observed along with a conference room door. There was no readily apparent exit sign inside the corridor. The first visible exit sign was at the entrance to the Administrative lobby on the other side of the exit access door to the lobby.

This was confirmed with Staff M and Staff N during tour.

On 08/02/16 at 9:47 AM a door was observed opposite stair 147. The door was observed to be a glass door in an outside glass wall. The door was not an exit discharge, but had a sign that read "emergency use only " .

On 08/02/16 at 9:47 AM Staff Q confirmed the door was not an exit discharge, but that the double doors about 10 yards down the corridor was.



03245

On 08/04/16 at 3:20 PM, in the presence of Staff Q, an evacuation plan was observed in the conference room on the ground floor of the Administrative building. The evacuation route contained a path of egress from the Administrative building. This route led through the metal door at the entrance into the in-patient unit.

Staff Q stated this evacuation plan was not current and the evacuation route for this area of the building was the stairwell and not the door into the in-patient unit.

Based on observation and interview, the facility failed to have exit and directional signage in accordance with 7.10. This had the potential to affect all patients of the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

On 08/02/16 at 9:56 AM a tour was conducted of the lower level with Staff Q and R.

On 08/02/16 at 11:15 AM dining area b103 was observed to be without any exit signage.

On 08/02/16 at 11:15 AM in an interview, Staff Q and R confirmed the observation.

On 08/02/16 at 2:35 PM observation of the dining room near corridor c101 revealed it had an outside, window door that was not an exit discharge. A no exit sign was not observed.

On 08/02/16 at 2:35 PM in an interview, Staff Q confirmed the door was not an exit discharge.

Based on review of architectural drawings, observation and interview, the facility failed to ensure the construction protecting compartments were free of penetrations to maintain its protective rating(s). This has the potential to affect all patients in the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

During tour with Staff M and N on 08/01/06 at 9:45 AM, the smoke barrier at the entrance to C2 unit was observed with a three quarter diameter electrical flexible wire which had a penetration in the annular space around the wire.


Staff M and N verfied the findings at the time of the observation.


On 08/02/16 at 9:56 AM a tour was conducted with Staff Q and R.

On 08/02/16 at 10:13 AM observation above the ceiling of the two hour barrier over the door to the med room on Unit B as seen within revealed an insulated pipe with an annular space between zero and 45 degrees.

On 08/02/16 at 10:13 AM in an interview, Staff R confirmed the observation.

On 08/02/16 at 10:27 AM observation of the southern two hour barrier inside locker b111c revealed corrugated conduits with open annular spaces between 180 and 360 degrees.

On 08/02/16 at 10:27 AM in an interview, Staff R confirmed the observation.

During tour with Staff M and N on 08/02/16 at at 10:30 AM, the smile barrier inside mechanical room D202 was observed with two one and a half inch penetrations around nonflexible metal conduit. When inside the room, the smoke barrier to the left of doors leading to the corridor was observed with a two foot wide by one foot high opening at the top right side of the barrier. The upper portion of the smoke barrier partition was observed with insulation between the drywall and upper decking. An additional penetration was observed around an I-beam in the barrier.


The findings were verified with Staff M and N at the time of the oberservation.


On 08/02/16 at 10:32 AM observation above the ceiling of the two hour barrier inside the med room of unit B revealed to the left of the door an insulated pipe with an annular space, three one inch empty penetrations, one open conduit holding blue wires, and one open conduit holding blue wires and one orange wire.

On 08/02/16 at 10:32 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 10:48 AM observation above the ceiling of the two hour barrier in group therapy room b130 revealed a one and a half inch open conduit holding orange and blue wiring and one open junction box with an open conduit traveling to the barrier.

On 08/02/16 at 10:48 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 10:56 AM observation above the ceiling of the two hour barrier above the double doors leading out of unit B, as seen from within unit B, revealed on the right side an insulated pipe with an annular space.

On 08/02/16 at 10:56 AM in an interview, Staff R confirmed the finding.

During tour with Staff M and N on 08/02/16 at 11:00 AM, the smoke barrier at the entrance of the D2 unit was observed with two water pipes which passed through the barrier inside metal conduit sleeves. A gap of approximately one each inch each was observed inside the conduit on one side of each of the two water pipes.


Staff M and N verified the findings at the time of the observation.


On 08/02/16 at 11:07 AM observation above the ceiling of the two hour barrier as seen from within laundry room b105 revealed an open conduit holding blue, orange, and gray wires and an insulated pipe with an annular space.

On 08/02/16 at 11:07 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 11:26 AM observation above the ceiling of the two hour barrier above the double doors perpendicular to room b102c revealed unrated foam filling annular spaces around sprinkler lines, and a one inch conduit with an annular space.

On 08/02/16 at 11:26 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 11:35 AM observation above the ceiling of the one hour barrier near the door to bathroom opposite dining area b103 revealed an insulated pipe with an annular space between it and its sleeve. Observation of the double doors just south and in the same plane of this area and perpendicular to the elevator revealed they were unrated.

On 08/02/16 at 11:35 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 11:46 AM observation of the two hour barrier protecting an elevator space revealed in the east wall two one foot by two foot ventilation grills, one near the ceiling and, 180 degrees down, one near the floor. The ventilation grills were not observed to have any dampers within. In addition, along the east wall as seen from outside the room, several one inch penetrations

On 08/02/16 at 11:46 AM in an interview, Staff Q confirmed the observation.

1On 08/02/16 at 2:11 PM observation above the ceiling of the two hour barrier over the double door perpendicular to office b102c revealed an heating, ventilation, and cooling duct and an insulated pipe with annular spaces and one open conduit holding orange wiring.

On 08/02/16 at 2:11 PM in an interview, Staff R confirmed the finding.

On 08/02/16 at 2:45 PM observation above the ceiling of the one hour barrier as seen above the desk in exam room c105 revealed a one and a half inch penetration with a single blue wire traveling through it.

On 08/02/16 at 2:45 PM in an interview, Staff R confirmed the finding.

On 08/02/16 at 2:54 PM observation above the ceiling of the one hour barrier as seen within group therapy room c107 revealed one open smooth conduit holding blue and white wiring.

On 08/02/16 at 2:54 PM in an interview, Staff R confirmed the finding.

On 08/03/16 at 9:15 AM a tour was taken of the facility with Staff Q.

On 08/03/16 at 2:03 PM observation above the ceiling of the one hour barrier in the north wall of laundry room d122 (seen inside room d122) revealed an open one inch smooth conduit.

On 08/03/16 at 2:03 PM in an interview, Staff Q confirmed the finding.






03245

Based on review of architectural drawings, observation and interview, the facility failed to ensure the protective construction around its hazardous areas were free of penetrations. This had the potential to affect all patients in the facility. The facility had a census of 111 patients.


Findings include:


On 08/02/16 at 11:15 AM during tour with with Staff M and Staff N, a soiled utility room located on the D2 Unit, by room D215 was observed with penetrations in the fire rated barrier. Observations of the fire rated barrier inside the soiled utility room revealed the following penetrations:

*Over the door a three inch diameter and a two inch diameter curved conduit were observed with penetrations inside each conduit. The I-beam in the upper left corner of the fire barrier was observed with a half inch by two foot gap between the beam and drywall.

A review of architectural drawings revealed the soiled utility room with a one hour fire rated barrier.

Staff M and Staff N verified the penetrations at the time of the observation and the fire rated construction on the architectural drawings.






21521

Based on observation and interview the facility failed to ensure each hazardous space had doors that self closed and the rated, protective construction was free of penetrations. This has the potential to affect all patients in the facility. The facility had a census of 111 patients.

Findings include:

On 08/01/16 at 1:25 PM a tour was taken of the facility with Staff Q and R.

On 08/01/16 at 1:35 PM the double doors leading to a mechanical space that contained a boiler room was observed to have an astaragal that, depending on the order when the doors closed, would not allow the latching hardware to close and latch the doors. The doors were observed in a one hour barrier.

On 08/01/16 at 1:35 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:37 PM, observation of the one hour barrier surrounding mechanical space 131 revealed to the right of the double doors (seen within the room) the wall had conduits with annular spaces and it did not extend all the way to the deck.

On 08/01/16 at 1:37 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:47 PM, observation of the one hour barrier surrounding mechanical space 131 as seen from the single commode unisex bathroom revealed a one inch open conduit with a blue wire traveling through it.

On 08/01/16 at 1:47 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:50 PM, observation of the one hour barrier between mechanical space 131 and the men ' s bathroom as seen from the mechanical space near the 90 degree angle revealed one sprinkler line, one drain line, and two drain pipes with annular spaces.

On 08/01/16 at 1:50 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:55 PM, observation of the one hour barrier between mechanical space 131 and room 122 (as seen at the 90 degree angle from the mechanical space) revealed three drainage pipes with annular spaces and two pipes with annular spaces next to an I-beam.

On 08/01/16 at 1:55 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:58 PM observation of the one hour barrier between mechanical space 131 and room 122 (as seen within the mechanical space and north of the obtuse angle) revealed three heating, ventilation, and cooling ducts with annular spaces.

On 08/01/16 at 1:58 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:59 PM, observation of the one hour barrier between mechanical space 131 and room 122 (as seen within the mechanical space north of the right angle and south of double doors to the outside) revealed a one inch conduit running through an open one foot by one foot square.

On 08/01/16 at 1:59 PM in an interview, Staff R confirmed the finding.





03245

On 08/03/16 at 2:10 PM during tour with Staff M, Staff N, and Staff Q, observations revealed an office, A236, in the Administrative building on the ground level which contained a large amount of paper stacked on shelves, the desk, and file cabinets. The door to the corridor lacked a self closing device. This was confirmed with all three staff at the time of the observation.

On 08/03/16 at 2:30 PM, Staff M provided an email from Office A236's occupant regarding a plan of correction for the paper overload in the office. The email was sent to Staff M on 11/24/14. The projected date of completion in the email was 12/12/14.

Based on observation and interview, the facility failed to ensure the rated construction protecting its stairwells were free of penetrations. This has the potential to affect all patients in the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

On 08/02/16 at 9:56 AM a tour was conducted of the lower level with Staff Q and R.

On 08/02/16 at 9:56 AM observation above the ceiling of the two hour barrier protecting stair B139 as seen from the corridor revealed a one inch open conduit.

On 08/02/16 at 9:56 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 10:05 AM observation above the ceiling of the two hour barrier protecting stair b139 as seen from room b109 revealed three conduits with annular spaces and one open junction box with an open conduit within.

On 08/02/16 at 10:05 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 2:03 PM observation above the ceiling of the two hour barrier protecting stair b138 as seen from within the stairwell revealed one insulated pipe and three smooth conduits with annular spaces and one sprinkler line with an annular space between it and its sleeve.

On 08/02/16 at 2:03 PM in an interview, Staff R confirmed the finding.

On 08/03/16 at 9:15 AM a tour was taken of the facility with Staff Q.

On 08/03/16 at 9:44 AM observation above the ceiling of the one hour barrier protecting stair c108 and seen opposite exam room c105 revealed an open one inch conduit and an annular space around another one inch conduit.

On 08/03/16 at 9:44 AM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 10:41 AM observation above the ceiling of the one hour barrier protecting stair c129 as seen from the clinical area revealed four one inch open conduits.

On 08/03/16 at 10:41 AM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 1:26 PM observation of the one hour barrier protecting stair d112 as seen from within electric room d111 revealed multiple conduits grouped together creating an annular space in the area between 45 and 275 degrees. One conduit was observed to be open with a blue wiring traveling through it.

On 08/03/16 at 1:26 PM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 2:21 PM observation above the ceiling of the one hour barrier protecting stair d128 as seen from within the clinical area revealed a one inch open conduit to the left of the door.

On 08/03/16 at 2:21 PM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 2:33 PM observation above the ceiling of the one hour barrier protecting stair d128 as seen from within the stairwell revealed annular spaces around insulated pipes, around two smooth conduits, and between a sprinkler line and its sleeve.

On 08/03/16 at 2:33 PM in an interview, Staff Q confirmed the finding.

Based on review of facility documentation, observations and staff interview, the facility failed to ensure the fire alarm system was maintained to ensure proper working condition. This could potentially affect all patients in the facility. The facility census was 111 patients.

Findings include:

Observations on 08/01/16 through 08/04/16 revealed the fire alarm system panel in the Administrative Switchboard office and a remote annunciator panel in the Treatment Mall building displayed an amber colored trouble light displaying "network operating in degraded style ".

Staff Q stated in an interview, the trouble light came on the previous Friday (07/29/16). Staff Q provided documentation a telephone call was made to the fire alarm service company on 07/29/16 to evaluate the trouble light on the fire alarm panel.

On 08/04/16 at 10:12 AM, Staff Q stated the fire alarm company arrived (six days after calling the company) to check the fire alarm panel. Staff Q stated the fire alarm monitor in Staff Q's office had a loose wire, which was now reconnected. Staff Q then provided documentation the fire alarm system was functioning normally.



21521

On 08/01/16 at 1:25 PM a tour was taken of the facility with Staff Q and R.

During the tour strobes with the following addresses were observed: 497, 503, 504, and 491.

On 08/04/16 a review of the facility's life safety code documentation was completed. The review did not reveal where these strobes had been tested.

On 08/04/16 at 2:20 PM in an interview, Staff Q explained all strobes had been replaced earlier in the year. He explained they would get tested in separate groupings throughout the year. He was unable to show if they were tested upon installation.

Based on observation, interview, and document review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients in the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

On 08/03/16 at 11:30 AM a fire fusible link damper was observed in the east wall of the exam room c105.

On 08/03/16 at 11:15 AM a fire fusible link damper was observed above the drop down ceiling in the wall above the door to the right of the elevators as seen within lobby d100.

On 08/03/16 at 11:18 AM a fire fusible link damper was observed above the drop down ceiling in the wall above the door to the left of the elevators as seen within lobby d100.

On 08/04/16 a review of the facility's life safety code documentation was completed. The review revealed the facility's fire and smoke dampers were tested on 06/23/16. The review revealed fusible link fire dampers 14, 36, 38, 41, 68, and 71 had had only a visual inspection.

On 08/04/16 at 10:35 AM Staff Q verified the existence of the dampers in the exam room and in lobby d100 and stated they had not been tested.

Based on observations and staff interviews, the facility failed to ensure sprinkler heads were maintained in accordance with the code at 8.2.5 and NFPA 25, 2-1, failed to maintain fire rated barriers and smoke barriers in accordance with the code at 8.2.5, failed to ensure smoke detectors were located in accordance with the code at 9.6.1.4 and NFPA 72, 2-3.5.1, failed to ensure doors in a two hour fire rated barrier were as required by the code, failed to ensure the one hour rated construction protecting the stairwell was free of penetrations. This could potentially affect all patients in the facility. The census was 111 patients.


Findings include:


Sprinkler Heads

On 08/02/16 between 1:14 PM and 3:00 PM during tour with Staff M and Staff N, the following sprinkler heads were observed heavily coated with dust and dirt and/or were missing escutcheon rings:


a) The kitchen was observed with at least nine sprinkler heads which were heavily coated with dust and dirt in the food prep areas.


b) The sprinkler head in the corridor in the Treatment Mall area by room A205 and inside room A242 classroom were each observed missing an escutcheon ring.


The findings were confirmed with Staff M and Staff N at the time of the observation.


Fire Rated Barriers

The following two hour fire rated barriers were observed with penetrations, or with insulation covering the surface of the upper portion of the barrier surface, resulting in the inability to confirm the barrier was intact:

a) The two hour fire rated barrier inside the Information Technology (IT) office A220, the two hour fire rated barrier was observed with:
*Two penetrations around one inch conduit over the corridor door. The opposite side to the fire barrier was observed with the same opening;
*An opening approximately four inches wide by two inches tall around a red metal beam in the right corner of the barrier inside the Q.A.P.I.;
*Inside A211, Information Director's Office, the inside of a curved three quarter inch conduit, and at the bottom was silver covered insulation which was lying against the surface of the barrier. The top of the barrier was unable to be viewed due to the insulation.


Staff M and Staff N lacked knowledge as to whether the insulation had a fire rating;


*Inside Room A208 the barrier contained a half inch diameter curved conduit with a blue wire, which was unsealed inside the conduit. The same silver colored insulation covered a portion of the fire wall, not permitting visualization of the barrier.


b) Inside the library, the fire barrier between the library and the IT office, was observed with two half inch diameter curved conduits with blue and white wires, which were open inside the conduit.


c) The two hour fire rated barrier by the Chapel and room F217 was observed with:
*Over the corridor doors, a half inch diameter curved conduit with a blue wire was unsealed inside the conduit;
*Inside the chapel a three quarter inch diameter curved conduit which was open inside, and corrugated metal roof decking measuring approximately 23 feet in width which was observed with half to one inch opening between the fire barrier and decking.


The doors in this two hour fire rated barrier was observed with 20 minute fire rated doors. This was confirmed with Staff M on tour. Staff M stated the doors lacked the appropriate fire resistant rating.


d) The barrier separating the Recreation Center from the Treatment Mall area was identified as smoke barrier on 08/01/16 by Staff Q. Inside the Recreation Center, a storage room was observed which measured approximately 16 by six feet in diameter.


Penetrations in the Recreation Center storage room smoke barrier included :
*The left wall behind the door, approximately a six feet wide by a half to one inch high opening was observed underneath a metal strip between the concrete wall and drywall;
*The long wall between this storage room and the Peer Support Office was observed with an unsealed three quarter inch diameter metal conduit and a half inch metal conduit, both of which were open inside the conduits;
* The wall to the right of the door was observed with three metal conduits measuring three quarter inches each in diameter. The inside of the conduits were open around wires. The smoke barrier wall was observed with one layer of drywall.


The smoke barrier inside the Peer Support Center was observed with three conduits each measuring up to three quarter inches in diameter. The inside and annular spaces around the conduit were observed with penetrations. The upper portion of the smoke barrier was observed open approximately one inch in height between the drywall and roof decking the entire 16 foot width.


Inside the Recreation Center at the far right side of the smoke barrier over the vending machines, the smoke barrier was observed with an opening around copper pipes which penetrated the barrier. The opening was approximately 12 inches wide and eight inches in height.


Over the corridor doors between the Recreation Center and Treatment Mall, (on the Treatment Mall side), the smoke barrier was observed with only one layer of drywall between the storage room and corridor. Four penetrations were observed in this barrier to the right of the corridor doors. These were the same penetration observed in the storage room to the right of the door.


Smoke Detectors

The following smoke detectors were observed closer than 36 inches from air supply/return diffusers:

In the Treatment Mall area
* Inside Conference Room A (Room 1301 on architectural drawings) located by the LAN Server room;
* Inside the IT Suite entrance by room A218.

In the Ground Level of the Administrative building, inside the Telecommunications Room 247 (located inside the classroom).

During tour, Staff M and Staff N confirmed the verified all of the findings in regard to sprinklers, fire and smoke barriers, fire doors, and smoke detector locations.



21521

Vertical Openings.

On 08/01/16 at 1:25 PM a tour was taken of the facility with Staff Q and R.

On 08/01/16 at 2:05 PM observation on the north side and above the ceiling over the corridor double doors in the one hour barrier between office 152 and exam room 136 revealed a six inch by six inch square cut into the drywall and two one inch open penetrations with one line running through each, and one empty one inch penetration.

On 08/01/16 at 2:05 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 2:24 PM observation above the ceiling of the one hour barrier between corridor 129 and waiting room 150 (as seen from the corridor) revealed two insulated pipes with annular spaces and two corrugated conduits with adjoining annular spaces.

On 08/01/16 at 2:24 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 2:33 PM observation of the door in the one hour barrier between corridor 114 and 129 revealed it was cracked and its self closing and latching hardware did not close and latch the door.

On 08/01/16 at 2:33 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 3:13 PM observation above the ceiling of the one hour barrier over stairway 100 door revealed a two inch by two inch square opening and openings between the barrier and the corrugated deck.

On 08/01/16 at 3:13 PM in an interview, Staff R confirmed the finding.

Based on observations, review of architectural drawings, and staff interviews, the facility's two hour fire wall between this building and a non-conforming business occupancy building lacked a two hour fire resistance rating. The non-conforming building failed to maintain the sprinkler heads, fire and smoke barriers, and required smoke detector locations. This could potentially affect all patients in the facility. The census on the first day of survey was 111 patients.

Findings include:

On 08/01/16 between 12:36 PM and 2:31 PM, and on 08/02/16 between 9:30 AM and 11:24 AM, a tour was conducted with Staff M and Staff N of the ground floor. This tour revealed the two hour fire rated barrier between this facility and the business occupancy was not maintained and lacked a two hour fire resistance rating as follows:

The fire barrier located between the facility's common corridor and the Lab/Clinic/Admissions area was observed with penetrations.

On the healthcare side of the corridor:
*A chiller and hot water pipes (two six inch pipes) had a whitish gray colored insulation type material around the pipes in the annular opening around the pipes;
*A four inch and six inch opening were observed in the drywall outside clinic room 1360.1;
*Over the 1360.1 door a three inch diameter conduit was open around wires inside the conduit.

On the Treatment Mall side of the fire barrier:
*Inside the Lab area a one inch opening around a cable and a gap in the one layer of drywall over the clock.

Staff M and Staff N were unsure how the fire barrier was constructed as the drywall was observed with brown colored backing, and the number of drywall layers could not be confirmed;

*Over the exit door to the healthcare corridor by the double elevators, a concrete block wall was observed approximately eight to 10 feet in height. This block was open at the top of the concrete wall approximately 16 to 20 feet in width. A three inch conduit, a half inch conduit, and two three quarter inch metal conduits were observed open and unsealed in this concrete wall.

The fire barrier located between the double elevators and open courtyard was observed with penetrations:
*Over the fire doors on the Treatment Mall side observed were one three quarter inch diameter conduit open around wires inside the conduit, and a two foot wide by two inch high opening at the top in which silver covered insulation was inserted.

The fire barrier located near C2 Unit and the entrance to the Treatment Mall (between two courtyards) was observed with penetrations as follows:
*On the C2 unit side the wall was observed with a two inch opening to the left side when facing the fire barrier doors;
*The Treatment Mall side of the fire barrier was observed with silver covered insulation which was in contact with a large portion of the fire barrier surface, disallowing visualization of the entire fire barrier wall. The top portion of the fire barrier was observed with an approximately 16 foot wide by eight to 12 inches high openings between the barrier and the corrugated metal decking.

Staff N was unable to confirm the fire resistance rating of the barrier on tour. A review of architectural drawings at the time of tour revealed this fire rated barrier had a two hour fire resistance rating.

All penetrations and observations of the fire barriers, and architectural drawings, were confirmed with Staff M and Staff N during tour.

Based on observation and interview, the facility failed to ensure all corridor openings had doors where required, and all corridor doors closed with their latching hardware latching. This had the potential to affect all patients in the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

On 08/01/16 at 2:00 PM, a tour with Staff M and Staff N and observations of the B2 in-patient unit revealed the patient room B220 lacked a corridor door at the entrance into the room. A female patient was observed inside the room at the time of observation. The corridor doorframe was observed with a vinyl shower curtain hanging at the door. Staff M stated the patient tore the door up and the facility ordered a door a couple of days ago; however, the door had not been delivered.

On 08/02/16 at 9:56 AM a tour was conducted of the lower level with Staff Q and R.

On 08/02/16 at 1:50 PM observation of the corridor door to patient room 118 revealed it did not completely close and latch because the door would stick to the top part of the frame.

On 08/02/16 at 1:50 PM in an interview, Staff Q and R confirmed the observation.

On 08/03/16 at 9:15 AM a tour was taken of the facility with Staff Q.

On 08/03/16 at 10:23 AM the corridor door to patient room c118 did not close as it would become stuck on the frame making it unable to close and latch.

On 08/03/16 at 10:23 AM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 2:17 PM the corridor door to patient room d130 was observed to stick on the frame preventing it from closing and latching.

On 08/03/16 at 2:17 PM in an interview, Staff Q confirmed the finding.




03245

Based on observation and interview, the facility failed to ensure compliance with 7.10.8.1. This had the potential to affect all patients in the facility. The facility had a census of 111 patients.

Findings include:

On 08/01/16 at 1:32 PM, a tour was conducted with Staff M and Staff N.

On the ground level of the Administrative building, an open stairwell was observed near the entrance of the in-patient building. The stairwell was observed with an illuminated exit sign at the top of the stairwell. A locked metal door near the top of the stairs and was observed with a sign over the door that contained the following words: "Do Not Enter When Lit ".

When questioned as to the path of egress in this area, Staff M stated the path of egress was through the metal door leading into the in-patient unit.

An egress corridor was observed in the Administrative building on the ground level by the police department. This corridor was approximately 25 feet in length and was located between the in-patient units and the Administration building lobby/atrium area. Both ends of this corridor were observed with latching doors. An exit sign was observed on the outside of the door closest to the in-patient unit. Upon entering the corridor, two unlocked public restrooms were observed along with a conference room door. There was no readily apparent exit sign inside the corridor. The first visible exit sign was at the entrance to the Administrative lobby on the other side of the exit access door to the lobby.

This was confirmed with Staff M and Staff N during tour.

On 08/02/16 at 9:47 AM a door was observed opposite stair 147. The door was observed to be a glass door in an outside glass wall. The door was not an exit discharge, but had a sign that read "emergency use only " .

On 08/02/16 at 9:47 AM Staff Q confirmed the door was not an exit discharge, but that the double doors about 10 yards down the corridor was.



03245

On 08/04/16 at 3:20 PM, in the presence of Staff Q, an evacuation plan was observed in the conference room on the ground floor of the Administrative building. The evacuation route contained a path of egress from the Administrative building. This route led through the metal door at the entrance into the in-patient unit.

Staff Q stated this evacuation plan was not current and the evacuation route for this area of the building was the stairwell and not the door into the in-patient unit.

Based on observation and interview, the facility failed to have exit and directional signage in accordance with 7.10. This had the potential to affect all patients of the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

On 08/02/16 at 9:56 AM a tour was conducted of the lower level with Staff Q and R.

On 08/02/16 at 11:15 AM dining area b103 was observed to be without any exit signage.

On 08/02/16 at 11:15 AM in an interview, Staff Q and R confirmed the observation.

On 08/02/16 at 2:35 PM observation of the dining room near corridor c101 revealed it had an outside, window door that was not an exit discharge. A no exit sign was not observed.

On 08/02/16 at 2:35 PM in an interview, Staff Q confirmed the door was not an exit discharge.

Based on review of architectural drawings, observation and interview, the facility failed to ensure the construction protecting compartments were free of penetrations to maintain its protective rating(s). This has the potential to affect all patients in the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

During tour with Staff M and N on 08/01/06 at 9:45 AM, the smoke barrier at the entrance to C2 unit was observed with a three quarter diameter electrical flexible wire which had a penetration in the annular space around the wire.


Staff M and N verfied the findings at the time of the observation.


On 08/02/16 at 9:56 AM a tour was conducted with Staff Q and R.

On 08/02/16 at 10:13 AM observation above the ceiling of the two hour barrier over the door to the med room on Unit B as seen within revealed an insulated pipe with an annular space between zero and 45 degrees.

On 08/02/16 at 10:13 AM in an interview, Staff R confirmed the observation.

On 08/02/16 at 10:27 AM observation of the southern two hour barrier inside locker b111c revealed corrugated conduits with open annular spaces between 180 and 360 degrees.

On 08/02/16 at 10:27 AM in an interview, Staff R confirmed the observation.

During tour with Staff M and N on 08/02/16 at at 10:30 AM, the smile barrier inside mechanical room D202 was observed with two one and a half inch penetrations around nonflexible metal conduit. When inside the room, the smoke barrier to the left of doors leading to the corridor was observed with a two foot wide by one foot high opening at the top right side of the barrier. The upper portion of the smoke barrier partition was observed with insulation between the drywall and upper decking. An additional penetration was observed around an I-beam in the barrier.


The findings were verified with Staff M and N at the time of the oberservation.


On 08/02/16 at 10:32 AM observation above the ceiling of the two hour barrier inside the med room of unit B revealed to the left of the door an insulated pipe with an annular space, three one inch empty penetrations, one open conduit holding blue wires, and one open conduit holding blue wires and one orange wire.

On 08/02/16 at 10:32 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 10:48 AM observation above the ceiling of the two hour barrier in group therapy room b130 revealed a one and a half inch open conduit holding orange and blue wiring and one open junction box with an open conduit traveling to the barrier.

On 08/02/16 at 10:48 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 10:56 AM observation above the ceiling of the two hour barrier above the double doors leading out of unit B, as seen from within unit B, revealed on the right side an insulated pipe with an annular space.

On 08/02/16 at 10:56 AM in an interview, Staff R confirmed the finding.

During tour with Staff M and N on 08/02/16 at 11:00 AM, the smoke barrier at the entrance of the D2 unit was observed with two water pipes which passed through the barrier inside metal conduit sleeves. A gap of approximately one each inch each was observed inside the conduit on one side of each of the two water pipes.


Staff M and N verified the findings at the time of the observation.


On 08/02/16 at 11:07 AM observation above the ceiling of the two hour barrier as seen from within laundry room b105 revealed an open conduit holding blue, orange, and gray wires and an insulated pipe with an annular space.

On 08/02/16 at 11:07 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 11:26 AM observation above the ceiling of the two hour barrier above the double doors perpendicular to room b102c revealed unrated foam filling annular spaces around sprinkler lines, and a one inch conduit with an annular space.

On 08/02/16 at 11:26 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 11:35 AM observation above the ceiling of the one hour barrier near the door to bathroom opposite dining area b103 revealed an insulated pipe with an annular space between it and its sleeve. Observation of the double doors just south and in the same plane of this area and perpendicular to the elevator revealed they were unrated.

On 08/02/16 at 11:35 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 11:46 AM observation of the two hour barrier protecting an elevator space revealed in the east wall two one foot by two foot ventilation grills, one near the ceiling and, 180 degrees down, one near the floor. The ventilation grills were not observed to have any dampers within. In addition, along the east wall as seen from outside the room, several one inch penetrations

On 08/02/16 at 11:46 AM in an interview, Staff Q confirmed the observation.

1On 08/02/16 at 2:11 PM observation above the ceiling of the two hour barrier over the double door perpendicular to office b102c revealed an heating, ventilation, and cooling duct and an insulated pipe with annular spaces and one open conduit holding orange wiring.

On 08/02/16 at 2:11 PM in an interview, Staff R confirmed the finding.

On 08/02/16 at 2:45 PM observation above the ceiling of the one hour barrier as seen above the desk in exam room c105 revealed a one and a half inch penetration with a single blue wire traveling through it.

On 08/02/16 at 2:45 PM in an interview, Staff R confirmed the finding.

On 08/02/16 at 2:54 PM observation above the ceiling of the one hour barrier as seen within group therapy room c107 revealed one open smooth conduit holding blue and white wiring.

On 08/02/16 at 2:54 PM in an interview, Staff R confirmed the finding.

On 08/03/16 at 9:15 AM a tour was taken of the facility with Staff Q.

On 08/03/16 at 2:03 PM observation above the ceiling of the one hour barrier in the north wall of laundry room d122 (seen inside room d122) revealed an open one inch smooth conduit.

On 08/03/16 at 2:03 PM in an interview, Staff Q confirmed the finding.






03245

Based on review of architectural drawings, observation and interview, the facility failed to ensure the protective construction around its hazardous areas were free of penetrations. This had the potential to affect all patients in the facility. The facility had a census of 111 patients.


Findings include:


On 08/02/16 at 11:15 AM during tour with with Staff M and Staff N, a soiled utility room located on the D2 Unit, by room D215 was observed with penetrations in the fire rated barrier. Observations of the fire rated barrier inside the soiled utility room revealed the following penetrations:

*Over the door a three inch diameter and a two inch diameter curved conduit were observed with penetrations inside each conduit. The I-beam in the upper left corner of the fire barrier was observed with a half inch by two foot gap between the beam and drywall.

A review of architectural drawings revealed the soiled utility room with a one hour fire rated barrier.

Staff M and Staff N verified the penetrations at the time of the observation and the fire rated construction on the architectural drawings.






21521

Based on observation and interview the facility failed to ensure each hazardous space had doors that self closed and the rated, protective construction was free of penetrations. This has the potential to affect all patients in the facility. The facility had a census of 111 patients.

Findings include:

On 08/01/16 at 1:25 PM a tour was taken of the facility with Staff Q and R.

On 08/01/16 at 1:35 PM the double doors leading to a mechanical space that contained a boiler room was observed to have an astaragal that, depending on the order when the doors closed, would not allow the latching hardware to close and latch the doors. The doors were observed in a one hour barrier.

On 08/01/16 at 1:35 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:37 PM, observation of the one hour barrier surrounding mechanical space 131 revealed to the right of the double doors (seen within the room) the wall had conduits with annular spaces and it did not extend all the way to the deck.

On 08/01/16 at 1:37 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:47 PM, observation of the one hour barrier surrounding mechanical space 131 as seen from the single commode unisex bathroom revealed a one inch open conduit with a blue wire traveling through it.

On 08/01/16 at 1:47 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:50 PM, observation of the one hour barrier between mechanical space 131 and the men ' s bathroom as seen from the mechanical space near the 90 degree angle revealed one sprinkler line, one drain line, and two drain pipes with annular spaces.

On 08/01/16 at 1:50 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:55 PM, observation of the one hour barrier between mechanical space 131 and room 122 (as seen at the 90 degree angle from the mechanical space) revealed three drainage pipes with annular spaces and two pipes with annular spaces next to an I-beam.

On 08/01/16 at 1:55 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:58 PM observation of the one hour barrier between mechanical space 131 and room 122 (as seen within the mechanical space and north of the obtuse angle) revealed three heating, ventilation, and cooling ducts with annular spaces.

On 08/01/16 at 1:58 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 1:59 PM, observation of the one hour barrier between mechanical space 131 and room 122 (as seen within the mechanical space north of the right angle and south of double doors to the outside) revealed a one inch conduit running through an open one foot by one foot square.

On 08/01/16 at 1:59 PM in an interview, Staff R confirmed the finding.





03245

On 08/03/16 at 2:10 PM during tour with Staff M, Staff N, and Staff Q, observations revealed an office, A236, in the Administrative building on the ground level which contained a large amount of paper stacked on shelves, the desk, and file cabinets. The door to the corridor lacked a self closing device. This was confirmed with all three staff at the time of the observation.

On 08/03/16 at 2:30 PM, Staff M provided an email from Office A236's occupant regarding a plan of correction for the paper overload in the office. The email was sent to Staff M on 11/24/14. The projected date of completion in the email was 12/12/14.

Based on observation and interview, the facility failed to ensure the rated construction protecting its stairwells were free of penetrations. This has the potential to affect all patients in the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

On 08/02/16 at 9:56 AM a tour was conducted of the lower level with Staff Q and R.

On 08/02/16 at 9:56 AM observation above the ceiling of the two hour barrier protecting stair B139 as seen from the corridor revealed a one inch open conduit.

On 08/02/16 at 9:56 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 10:05 AM observation above the ceiling of the two hour barrier protecting stair b139 as seen from room b109 revealed three conduits with annular spaces and one open junction box with an open conduit within.

On 08/02/16 at 10:05 AM in an interview, Staff R confirmed the finding.

On 08/02/16 at 2:03 PM observation above the ceiling of the two hour barrier protecting stair b138 as seen from within the stairwell revealed one insulated pipe and three smooth conduits with annular spaces and one sprinkler line with an annular space between it and its sleeve.

On 08/02/16 at 2:03 PM in an interview, Staff R confirmed the finding.

On 08/03/16 at 9:15 AM a tour was taken of the facility with Staff Q.

On 08/03/16 at 9:44 AM observation above the ceiling of the one hour barrier protecting stair c108 and seen opposite exam room c105 revealed an open one inch conduit and an annular space around another one inch conduit.

On 08/03/16 at 9:44 AM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 10:41 AM observation above the ceiling of the one hour barrier protecting stair c129 as seen from the clinical area revealed four one inch open conduits.

On 08/03/16 at 10:41 AM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 1:26 PM observation of the one hour barrier protecting stair d112 as seen from within electric room d111 revealed multiple conduits grouped together creating an annular space in the area between 45 and 275 degrees. One conduit was observed to be open with a blue wiring traveling through it.

On 08/03/16 at 1:26 PM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 2:21 PM observation above the ceiling of the one hour barrier protecting stair d128 as seen from within the clinical area revealed a one inch open conduit to the left of the door.

On 08/03/16 at 2:21 PM in an interview, Staff Q confirmed the finding.

On 08/03/16 at 2:33 PM observation above the ceiling of the one hour barrier protecting stair d128 as seen from within the stairwell revealed annular spaces around insulated pipes, around two smooth conduits, and between a sprinkler line and its sleeve.

On 08/03/16 at 2:33 PM in an interview, Staff Q confirmed the finding.

Based on review of facility documentation, observations and staff interview, the facility failed to ensure the fire alarm system was maintained to ensure proper working condition. This could potentially affect all patients in the facility. The facility census was 111 patients.

Findings include:

Observations on 08/01/16 through 08/04/16 revealed the fire alarm system panel in the Administrative Switchboard office and a remote annunciator panel in the Treatment Mall building displayed an amber colored trouble light displaying "network operating in degraded style ".

Staff Q stated in an interview, the trouble light came on the previous Friday (07/29/16). Staff Q provided documentation a telephone call was made to the fire alarm service company on 07/29/16 to evaluate the trouble light on the fire alarm panel.

On 08/04/16 at 10:12 AM, Staff Q stated the fire alarm company arrived (six days after calling the company) to check the fire alarm panel. Staff Q stated the fire alarm monitor in Staff Q's office had a loose wire, which was now reconnected. Staff Q then provided documentation the fire alarm system was functioning normally.



21521

On 08/01/16 at 1:25 PM a tour was taken of the facility with Staff Q and R.

During the tour strobes with the following addresses were observed: 497, 503, 504, and 491.

On 08/04/16 a review of the facility's life safety code documentation was completed. The review did not reveal where these strobes had been tested.

On 08/04/16 at 2:20 PM in an interview, Staff Q explained all strobes had been replaced earlier in the year. He explained they would get tested in separate groupings throughout the year. He was unable to show if they were tested upon installation.

Based on observation, interview, and document review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients in the facility. The facility had a census of 111 patients and a capacity of 152 beds.

Findings include:

On 08/03/16 at 11:30 AM a fire fusible link damper was observed in the east wall of the exam room c105.

On 08/03/16 at 11:15 AM a fire fusible link damper was observed above the drop down ceiling in the wall above the door to the right of the elevators as seen within lobby d100.

On 08/03/16 at 11:18 AM a fire fusible link damper was observed above the drop down ceiling in the wall above the door to the left of the elevators as seen within lobby d100.

On 08/04/16 a review of the facility's life safety code documentation was completed. The review revealed the facility's fire and smoke dampers were tested on 06/23/16. The review revealed fusible link fire dampers 14, 36, 38, 41, 68, and 71 had had only a visual inspection.

On 08/04/16 at 10:35 AM Staff Q verified the existence of the dampers in the exam room and in lobby d100 and stated they had not been tested.

Based on observations and staff interviews, the facility failed to ensure sprinkler heads were maintained in accordance with the code at 8.2.5 and NFPA 25, 2-1, failed to maintain fire rated barriers and smoke barriers in accordance with the code at 8.2.5, failed to ensure smoke detectors were located in accordance with the code at 9.6.1.4 and NFPA 72, 2-3.5.1, failed to ensure doors in a two hour fire rated barrier were as required by the code, failed to ensure the one hour rated construction protecting the stairwell was free of penetrations. This could potentially affect all patients in the facility. The census was 111 patients.


Findings include:


Sprinkler Heads

On 08/02/16 between 1:14 PM and 3:00 PM during tour with Staff M and Staff N, the following sprinkler heads were observed heavily coated with dust and dirt and/or were missing escutcheon rings:


a) The kitchen was observed with at least nine sprinkler heads which were heavily coated with dust and dirt in the food prep areas.


b) The sprinkler head in the corridor in the Treatment Mall area by room A205 and inside room A242 classroom were each observed missing an escutcheon ring.


The findings were confirmed with Staff M and Staff N at the time of the observation.


Fire Rated Barriers

The following two hour fire rated barriers were observed with penetrations, or with insulation covering the surface of the upper portion of the barrier surface, resulting in the inability to confirm the barrier was intact:

a) The two hour fire rated barrier inside the Information Technology (IT) office A220, the two hour fire rated barrier was observed with:
*Two penetrations around one inch conduit over the corridor door. The opposite side to the fire barrier was observed with the same opening;
*An opening approximately four inches wide by two inches tall around a red metal beam in the right corner of the barrier inside the Q.A.P.I.;
*Inside A211, Information Director's Office, the inside of a curved three quarter inch conduit, and at the bottom was silver covered insulation which was lying against the surface of the barrier. The top of the barrier was unable to be viewed due to the insulation.


Staff M and Staff N lacked knowledge as to whether the insulation had a fire rating;


*Inside Room A208 the barrier contained a half inch diameter curved conduit with a blue wire, which was unsealed inside the conduit. The same silver colored insulation covered a portion of the fire wall, not permitting visualization of the barrier.


b) Inside the library, the fire barrier between the library and the IT office, was observed with two half inch diameter curved conduits with blue and white wires, which were open inside the conduit.


c) The two hour fire rated barrier by the Chapel and room F217 was observed with:
*Over the corridor doors, a half inch diameter curved conduit with a blue wire was unsealed inside the conduit;
*Inside the chapel a three quarter inch diameter curved conduit which was open inside, and corrugated metal roof decking measuring approximately 23 feet in width which was observed with half to one inch opening between the fire barrier and decking.


The doors in this two hour fire rated barrier was observed with 20 minute fire rated doors. This was confirmed with Staff M on tour. Staff M stated the doors lacked the appropriate fire resistant rating.


d) The barrier separating the Recreation Center from the Treatment Mall area was identified as smoke barrier on 08/01/16 by Staff Q. Inside the Recreation Center, a storage room was observed which measured approximately 16 by six feet in diameter.


Penetrations in the Recreation Center storage room smoke barrier included :
*The left wall behind the door, approximately a six feet wide by a half to one inch high opening was observed underneath a metal strip between the concrete wall and drywall;
*The long wall between this storage room and the Peer Support Office was observed with an unsealed three quarter inch diameter metal conduit and a half inch metal conduit, both of which were open inside the conduits;
* The wall to the right of the door was observed with three metal conduits measuring three quarter inches each in diameter. The inside of the conduits were open around wires. The smoke barrier wall was observed with one layer of drywall.


The smoke barrier inside the Peer Support Center was observed with three conduits each measuring up to three quarter inches in diameter. The inside and annular spaces around the conduit were observed with penetrations. The upper portion of the smoke barrier was observed open approximately one inch in height between the drywall and roof decking the entire 16 foot width.


Inside the Recreation Center at the far right side of the smoke barrier over the vending machines, the smoke barrier was observed with an opening around copper pipes which penetrated the barrier. The opening was approximately 12 inches wide and eight inches in height.


Over the corridor doors between the Recreation Center and Treatment Mall, (on the Treatment Mall side), the smoke barrier was observed with only one layer of drywall between the storage room and corridor. Four penetrations were observed in this barrier to the right of the corridor doors. These were the same penetration observed in the storage room to the right of the door.


Smoke Detectors

The following smoke detectors were observed closer than 36 inches from air supply/return diffusers:

In the Treatment Mall area
* Inside Conference Room A (Room 1301 on architectural drawings) located by the LAN Server room;
* Inside the IT Suite entrance by room A218.

In the Ground Level of the Administrative building, inside the Telecommunications Room 247 (located inside the classroom).

During tour, Staff M and Staff N confirmed the verified all of the findings in regard to sprinklers, fire and smoke barriers, fire doors, and smoke detector locations.



21521

Vertical Openings.

On 08/01/16 at 1:25 PM a tour was taken of the facility with Staff Q and R.

On 08/01/16 at 2:05 PM observation on the north side and above the ceiling over the corridor double doors in the one hour barrier between office 152 and exam room 136 revealed a six inch by six inch square cut into the drywall and two one inch open penetrations with one line running through each, and one empty one inch penetration.

On 08/01/16 at 2:05 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 2:24 PM observation above the ceiling of the one hour barrier between corridor 129 and waiting room 150 (as seen from the corridor) revealed two insulated pipes with annular spaces and two corrugated conduits with adjoining annular spaces.

On 08/01/16 at 2:24 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 2:33 PM observation of the door in the one hour barrier between corridor 114 and 129 revealed it was cracked and its self closing and latching hardware did not close and latch the door.

On 08/01/16 at 2:33 PM in an interview, Staff R confirmed the finding.

On 08/01/16 at 3:13 PM observation above the ceiling of the one hour barrier over stairway 100 door revealed a two inch by two inch square opening and openings between the barrier and the corrugated deck.

On 08/01/16 at 3:13 PM in an interview, Staff R confirmed the finding.