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Based on observations and confirmed by staff, the facility failed to ensure that the building is maintained as 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).
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 weeks of 3/4/13 & 3/11/13 while performing the building tour, it was observed that the building is six (6) stories in height and was originally constructed as a Type I (332) construction classification. However, it was observed that numerous electrical closets located in the "Wesson" building have floor penetrations approximately 12" x 16" in size. These penetrations are covered with what appears to be sheet metal painted gray. As a result of the penetrations being sealed with non-rated material, the required ceiling/floor assembly rating is not achieved.

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 corridor doors close and latch properly into their frames. There shall be no impediment to closing the door, only approved hold open devices may be used.

THE FINDINGS INCLUDE:

- During the morning hours of 3/12/13 while touring the facility, the following items were observed regarding corridor doors:

1) Three (3) of the doors to the on call rooms within the Emergency Room did not latch into the frames. The striker plates were covered over with tape preventing the doors from achieving positive latching.

2) The set of double doors leading into the patient radiation waiting room are not equipped with a latching mechanism.

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 corridor doors close and latch properly into their frames. There shall be no impediment to closing the door, only approved hold open devices may be used.
Section 19.3.6.3.3 states hold-open devices that release when the door is pushed or pulled shall be permitted. This is further clarified in the A.19.3.6.3.3 (appendix) stating doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 & 3/11/13 while performing the building tour, numerous corridor doors were noted as being deficient, these include but are not limited to the following locations:

1) The second, third and fourth floor levels of the "Wesson" building have corridor doors which double as the room's bathroom door as well. These doors are equipped with manually activated deadbolts (operable from both sides) to secure the doors into their frames when being used as bathroom doors. As a result, the doors can not be pulled closed into the corridor frame without manually unlatching the bathroom lock. In addition, if the deadbolt lock is in the extended position with the door in the open position, it acts as a deterrent from closing & latching the door into the frame.
Note: The deadbolts can't be extended into the corridor frames as there are no openings in the jambs for the throw latch bolt.

2) The "East" building 's patient care floor levels corridor doors are obstructed from closing due to trash barrel containers. These containers which are approximately 10" in depth are placed against a wall adjacent to the doors with an approximate 6" depth. As a result, the doors hit the containers, pushing them against the door jambs, preventing the doors from closing.
Note: The facility relocated some of these trash containers during survey.

3) The Anesthesia Office corridor door, labeled #1842, is equipped with a kick stop device preventing the door from closing as required.

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 smoke barrier doors are maintained as required.

THE FINDINGS INCLUDE:

- During the morning hours of 3/4/13 while touring the facility, it was observed that the fifth floor level smoke barrier door, located at the connector of the "Daly" Building, does not close as required. The door hits the top jamb preventing the door from sitting into the side jambs as designed.

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 exit passageways are maintained as required.
Section 7.2.6.2 states an exit passageway shall be separated from other parts of the building as specified in 7.1.3.2.
Section 7.1.3.2.1 states:
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.

THE FINDING INCLUDE:

- During the afternoon hours of 3/12/13 while touring the facility, it was observed that the door to the Gown Room (B 1015) located within the exit passage in the basement level has had the closing device disconnected. This door is part of the 2-hour rated exit passage and is required to be equipped with a self closing device.
Note: The Mass Mutual Building is 8-stories in height.

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 3/4/13 while touring the facility, it was observed that the fifth floor level "F" stairwell door is removed. As a result of the missing 90-minute labeled door, the Psychiatric Unit door, equipped with a 45-minute label, is now serving as the stairwell enclosure. Thus the stairwell rating is reduced from the required two hour fire resistance rating to a 45-minute 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. Section 7.2.2.3.2 states stairs shall have landings at door openings. Stairs and intermediate landings shall continue with no decrease in width along the direction of egress travel.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, the following items were observed regarding stairwells:

1) The following stairwells are not constructed with the minimum 44" clear width:
a) Stairwell "A" is 41" in width
b) Stairwell "B" is 37" in width
c) Stairwell "C" is 38" in width
d) Stairwell "D" is 41" in width
e) Stairwell "E" is 41" in width
f) Stairwell "F" is 41" in width
g) Stairwell "G" is 38" in width
In addition, many of these stairwells have radiators located at various landings reducing the travel width to less than 37" in numerous locations.

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 egress stairwells are properly designed & maintained. Section 7.7.3 states the exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/12/13 while touring the facility, it was observed that stairwells: "J"; #1 and #5 continue three (3) levels below the level of exit discharge. The stairs on the first and second floor levels are not equipped directional devices indicating that the level of discharge was in the upward direction.

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 maximum travel distances to exit egress locations are not exceeded. Section 19.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 100 ft (30 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 150 ft (45 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.4 states the travel distance between any point in a suite of sleeping rooms as permitted by 19.2.5 and an exit access door of that suite shall not exceed 100 ft (30 m) and shall meet the requirements of 19.2.6.2.2.
Section 19.2.5.6 states suites of sleeping rooms shall not exceed 5000 ft2 (460 m2).
Section 19.2.5.7 states suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2 (930 m2).
Section 19.2.5.8 suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 ft (30 m) and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 ft (15 m).

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/5/13 while touring the facility, the following items were observed:
1) The overall distance from Suite 1 to the nearest exit is 215'. The total allowable travel distance is 200' in a fully sprinklered building. In addition, as the floor plans do not specify 2-hour fire separations between buildings, and not all the buildings are equipped with a complete automatic sprinkler system, the additional 50' of additional travel distance can not be applied.
Note: This suite originally would have met the travel distance but a door which shows as still existing on the supplied floor plans has since been removed. With the removal of this door, the distance was increased dramatically as the other door exited to another corridor.

2) The patient room corridor doors #3425 and #3426 on the third floor level of the "East" Building are approximately 115' from the nearest exit door. (Please refer to ID Prefix Tag K056)

3) As noted in the initial comments K00, the facility submitted an "equivalency" letter for review for the oversized sleeping and non-sleeping suites. As stated, CMS requires an FSES to be performed to be deemed equivalent to the LSC. These suites and deficient issues are noted in the following locations:

a) Cardiac Surgery Intensive Care Unit (CSICU): sleeping suite listed as 10,282 square feet (sf)
b) Neonatal Intensive Care Unit (NICU): sleeping suite listed as 7,325 square feet (sf)
c) Continuing Care Nursery (CCN): no direct exit to a corridor
d) Operating Suite: non-sleeping suite listed as 20,394 square feet (sf) with a travel distance of 161 feet exceeding the allowable distance of 100 feet.

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

Based on observations and confirmed by staff, the facility failed to ensure egress doors are maintained as required. Section 7.2.1.5.1 states doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/12/13 while touring the facility, it was observed that the Davis Family Waiting area has a door with an exit sign located directly above. When the door was checked for operation, it was found to be in the locked position and only operable by key.
Note: Although this door is not a required exit door as multiple exits are provided within that location, the door is equipped with an exit sign signifying it is a means of egress.

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

Based on observations and confirmed by staff, the facility failed to ensure egress doors are maintained as required. Section 7.2.1.5.1 states doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/6/13 while touring the facility, it was observed that the third floor level connector which leads into the Medical Office Building has a set of double doors equipped with magnetic locking devices. The doors were observed in the locked position at the time of survey, and are not equipped with any type of override device for the locks' release. In addition, there is an exit sign located directly above the doors indicating that this is a means of egress from the connecting corridor.

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

Based on observations and confirmed by staff, the facility failed to ensure doors provided are of the proper width. Section 19.2.3.5 states the minimum clear width for doors in the means of egress shall be not less than 32 in. (81 cm) wide.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/6/13 while touring the facility, it was observed that the doors located on the first floor level of the "Wright" Building's office area are 30 inches wide.

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

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/6/13 while touring the facility, it was observed that the door, labeled # 3131, and part of the two hour fire rated barrier, did not close and latch as required. The door hit the top jamb preventing positive latching when released form the open position.

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

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/6/13 while touring the facility, it was observed that the third floor level connector which leads into the Medical Office Building has a set of double doors which also act as a 2-hour horizontal exit. When tested for operation, one of these doors would not latch in the closed position.

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 egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

- During the morning hours of 3/6/13 while performing the building tour, it was observed that light switches are mounted in the "S-Link" corridor and the "S-Link" stairwell which are accessible to staff, patients and visitors. When the switches were tested for operation, the entire corridor as well as the stairwell are not provided with the required illumination.

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 egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, it was observed that light switches are mounted in the main corridors and stairwells accessible to staff, patients and visitors. When the switches were tested for operation, the entire corridor as well as the stairwell are not provided with the required illumination. This was observed throughout the hospital.

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

Based on observations and confirmed by staff, exit signs are not provided as required. Section 7.10.1.2 states exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, exits shall be marked by an approved sign readily visible from any direction of exit access.

THE FINDINGS INCLUDE:

- During the morning hours of 3/6/13 while performing the building tour, it was observed that exit signs, on the seventh floor level rear area, are not installed as required. The following items were observed regarding exit signs:

1.) One of the exit signs is missing a directional arrow indicating that a turn is required to egress towards the exit stairwell.
2) One of the exit signs is facing the wrong direction, directing egress travel away from the egress stairwell.

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

Based on observations and confirmed by staff, exit signs are not provided as required. Section 7.10.1.2 states exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

THE FINDINGS INCLUDE:

- During the morning hours of 3/4/13 while performing the building tour, it was observed that exit sign on the fifth floor level Adult Psychiatric Unit is one sided. The sign does not specify the direction of travel to the stairwell from both directions as required.

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

Based on observations and confirmed by staff, manually operated fire alarm boxes (pull stations) are not installed as required. NFPA 72 section states each manual fire alarm box shall be securely mounted. The operable part of each manual fire alarm box shall be not less than 3-1/2 ft (1.1 m) and not more than 4-1/2 ft (1.37 m) above floor level.
Section 2-8.2.1 states manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.
Section 2-8.2.2 states manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor.
Section 2-8.2.3 states manual fire alarm boxes shall be mounted on both sides of group openings over 40 ft (12.2 m) in width. Manual fire alarm boxes shall be mounted within 5 ft (1.5 m) of each side of the opening.
Section 2-8.2.4 states additional manual fire alarm boxes shall be provided so that the travel distance to the nearest fire alarm box will not be in excess of 200 ft (61 m) measured horizontally on the same floor.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/12/13 while touring the facility, it was observed that the manual fire alarm boxes (pull stations) on the third floor level are located at a distance of 240' apart from each other.

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

Based on observations and confirmed by staff, manually operated fire alarm boxes (pull stations) are not installed as required. NFPA section 72 2-8.1 states each manual fire alarm box shall be securely mounted and the operable part of each manual fire alarm box shall be not less than 3-1/2 ft (42") and not more than 4-1/2 ft (54") above floor level.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, it was noted that manually operated fire alarm boxes (pull stations) are mounted at heights of 60 inches from the floor throughout the facility. These locations include but are not limited to each floor level of the "East" building.

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 smoke detectors are installed as required. NFPA 72 section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, smoke detectors were observed as being located closer than three feet (3') from a supply/return air diffuser. The detectors include but are not limited to the following locations:

1) Second floor level East Building Waiting Room
2) Third floor level North Building corridor

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

During the weeks of 3/4/13 and 3/11/13 while performing the building tour, the following items but not limited to were observed regarding the automatic sprinkler system:

Based on observations and confirmed by staff, sprinklers are not provided in all locations as required. 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. This facility is required to be fully sprinklered to meet the numerous exceptions which are utilized by installation of the automatic sprinkler system.
NFPA 13 section 5-13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states 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.
Section 4.6.12.1 requires any device, equipment, system, condition, arrangement, level of protection, or any other feature that is required for compliance with the provisions of the LSC to be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

" Central Sprinkler Co. " model GB20 sprinkler heads manufactured from 1989 to 2000 have been determined to be defective and must be replaced.

THE FINDINGS INCLUDE:

1) The patient rooms on the third floor level of the "East" Building are not protected by the automatic sprinkler system. As a result, the 50 feet of additional travel distance allowable (for a building equipped with a complete automatic sprinkler system) can not be utilized. Therefore, the corridor doors to patient room(s) #3425 & #3426 exceed the allowable 100 feet of travel distance. These doors are approximately 115' from the nearest exit door. (Please refer to ID Prefix Tag K036)

2) The non-sprinklered third floor level electrical room, #S3400S, is not separated by a 2-hour fire rated construction. The room is currently equipped with a non-rated door.

3) "Star Sprinkler Corporation" model G-20 recalled sprinkler heads are installed in the following areas:
- Daly Building's Atwater café
- first floor level Operating Room Suite
- Springfield Building's corridor and offices on the fifth floor level Psychological Unit.

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

Based on record review and staff interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure reading.

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 sprinkler heads are maintained as required. NFPA 25 section 2.2.1.1 requires sprinklers to be free of corrosion, foreign material, paint, and physical damage. Any sprinkler shall be replaced that is painted, corroded damaged, or loaded.
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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

The following items were noted during survey conducted 3/4/13 through 3/14/13:

1.) Several recessed sprinkler heads located behind the serving line of the cafeteria are painted with ceiling paint.

2) Record review of the quarterly automatic sprinkler system records available on revealed that there is no documentation of the alarm valve having been inspected internally in the past 5 years for the Wason 800 Building, Wason 700 Building (North Wing) and the Daly Building.

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

Based on observations, the facility did not ensure that portable electric heaters are prohibited from the building.
Section 9.7.8 states portable space-heating devices shall be prohibited in all health care occupancies.

THE FINDING INCLUDE:

- Observations while touring the facility on 3/6/13 at 10:00 A.M. revealed a portable electric heater in the second floor level Operating Room Services Coordinator's Room, labeled room # CH2050.

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 cylinders are properly secured. NFPA 99 section 8-3.1.11.2 (h) requires cylinder storage to meet the requirements of 4-3.5.2.1(b) 27 which states free-standing cylinders must be properly chained or supported in a stand or cart.

THE FINDINGS INCLUDE:

- Throughout the survey, during the weeks of 3/4/13 and 3/11/13, free standing "E" cylinders of oxygen were observed throughout the hospital's Main Building and Mass Mutual Building, typical of the free standing "E" cylinder observed in the penthouse (on 3/6/13) outside of the heli-pad area.

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 cylinders are properly secured. NFPA 99 section 8-3.1.11.2 (h) requires cylinder storage to meet the requirements of 4-3.5.2.1(b) 27 which states free-standing cylinders must be properly chained or supported in a stand or cart.
NFPA 99 section 4.3.1.1.2 (4) states the electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, the following items were observed regarding the storage of oxygen cylinders:

1) Several "E-cylinders" of oxygen were found free standing in various locations. These include but are not limited to the following locations:
-Fifth floor level Daly Building's Clean Utility Room
- Room S3500A (Nurse Conference Room)

2) The third floor level Oxygen Storage Room C3329A contains over 3000 cubic feet of stored oxygen. The room has a light switch mounted at 48" above the floor height. Note: Because of the amount of cylinders located around the perimeter of the room, it could not be determined if the room also had wall receptacles located behind the oxygen cylinders.

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

Based on observations, the facility failed to ensure the bulk oxygen tank is maintained in accordance with NFPA 50. Sections 2.2.1 and 2.2.1.12 require the minimum distance between any bulk oxygen storage container and any sidewalk or parked vehicle to be at least 10 feet.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning of 3/6/13 at 11:00 A.M. revealed that cars are parked within eight feet of the bulk oxygen tank.

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

Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1.
NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters.
Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.
Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.
Section 2.3.2 requires pressure gauges to be replace or tested every 5 years.
Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.
NFPA #13, section 4-1.1 states, a listed pressure gauge conforming to 5-15.3.2 shall be installed in each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.


THE FINDINGS INCLUDE:

- A review of the records available on 3/12/13 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valves are not operated annually through their full range and returned their normal position.
4. Control valve supervisory (tamper)switches are not tested at least semi-annually.
5. OS&Y are not lubricated annually.
6. The facility does not have documentation substantiating that the pressure gages have been tested or calibrated in the last 5 years.
7. The facility does not have documentation substantiating that the alarm valve has been internally inspected in the last 5 years.
8. The was no pressure gauge present above and below the sprinkler system check valve.

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 exit egress routes are properly maintained. Section 7.1.10.1 states means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning of 3/11/13, at 10:00 A.M. revealed that three of the exits, including two (2) from the library and one (1) from the Recovery Pad do not discharge to a public way.

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

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Based on observations and confirmed by staff, the facility failed to assure that all sprinkler valves are electrically supervised.

THE FINDINGS INCLUDE:

- The Post Indicator Valve (P.I.V.) located on the supply side of the automatic sprinkler system is not electrically supervised to the fire alarm system. The P.I.V. valve is located outside the building between the Chestnut Building and the Power Plant.

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

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Based on record review the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required. 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.
Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.

THE FINDINGS INCLUDE:

- Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure readings.

- Record review of the quarterly automatic sprinkler system records available on 3/6/13 revealed that there is no record of the alarm valve having been inspected internally in the past 5 years for the wet and dry system for the Chestnut building.

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

Based on record review and staff interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

- Record review and interview with a facilities supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure reading.

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. 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

- Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of monthly automatic sprinkler pressure readings.

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

Based on observations and confirmed by staff, sprinklers are not provided in all locations as required. Section 21.1.6.3 states buildings of two or more stories in height housing ambulatory health care facilities shall be of Type I(443), Type I(332), Type II(222), Type II(111), Type III(211), Type IV(2HH), or Type V(111) construction. (See 8.2.1.)
Exception: Buildings constructed of Type II (000), Type III (200), or Type V(000), if protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. This facility is required to be fully sprinklered as it is of Type II (000) construction. NFPA 13 section 5-13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states 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.
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 hours of 3/13/13 while performing the building tour, it was observed that the electrical rooms are not protected by automatic sprinkler system. These rooms contain numerous ducts which penetrate the 2-hour fire rated walls. The ducts do not have access panels on either side of the walls to determine if fire dampers are installed within the ductwork as required.

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

*************************************************

Based on observations and confirmed by staff, stairwells are not maintained as required. Section 21.3.1 states protection of vertical openings shall be in compliance with section 8.2.5. Section 8.2.5.1 states every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation.

THE FINDINGS INCLUDE:

- During the morning hours of 3/13/13 while performing the building tour, it was observed that the stairwell door labeled #2032 does not latch when in the closed position. It was noted that the electronic door strike was malfunctioning preventing positive latching from occurring.

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

*********************************************

Based on observation and confirmed by staff, the facility failed to provide two conforming smoke compartments as required. Section 21.3.7.2 states ambulatory health care facility shall be divided into not less than two smoke compartments.

THE FINDINGS INCLUDE:

- During the morning hours of 3/13/13 while performing the building tour, it was observed that the facility did not provide a conforming smoke barrier on the 1st and 2nd floors of the building. According the building floor plans provided, the 1st floor is 29,803 square feet (sf.) in size, and the 2nd floor is 25,167 sf. in size.

NOTE: As noted in the initial comments K00 in Bldg #01, the facility submitted an "equivalency" letter for review for various deficiencies identified by the hospital prior to survey. An equivalency was also provided for the lack of smoke barriers in building #04. As stated, CMS requires an FSES to be performed to be deemed equivalent to the LSC.

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. 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

- Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure readings.

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

Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1.
NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters.
Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.
Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.
Section 2.3.2 requires pressure gauges to be replace or tested every 5 years.
Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.
NFPA #13, section 4-1.1 states, a listed pressure gauge conforming to 5-15.3.2 shall be installed in each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.


THE FINDINGS INCLUDE:

- A review of the records available on 3/12/13 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valves are not operated annually through their full range and returned their normal position.
4. Control valve supervisory (tamper) switches are not tested at least semi-annually.
5. OS&Y are not lubricated annually.
6. The facility does not have documentation substantiating that the pressure gages have been tested or calibrated in the last 5 years.
7. The facility does not have documentation substantiating that the alarm valve has been internally inspected in the last five (5) years.
8. The was no pressure gauge present below the sprinkler system check valve.
9. Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure readings.



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

Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1.
NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters.
Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.
Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.
Section 2.3.2 requires pressure gauges to be replace or tested every 5 years.
Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.
NFPA #13, section 4-1.1 states, a listed pressure gauge conforming to 5-15.3.2 shall be installed in each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.
NFPA 25 section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

- A review of the records available on 3/12/13 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valves are not operated annually through their full range and returned their normal position.
4. Control valve supervisory (tamper) switches are not tested at least semi-annually.
5. OS&Y valves are not lubricated annually.
6. The facility does not have documentation substantiating that the pressure gages have been tested or calibrated in the last 5 years.
7. The facility does not have documentation substantiating that the alarm valve has been internally inspected in the last 5 years.
8. The was no pressure gauge present above and below the sprinkler system check valve.
9. Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure readings.

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 the building is maintained as 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).
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 weeks of 3/4/13 & 3/11/13 while performing the building tour, it was observed that the building is six (6) stories in height and was originally constructed as a Type I (332) construction classification. However, it was observed that numerous electrical closets located in the "Wesson" building have floor penetrations approximately 12" x 16" in size. These penetrations are covered with what appears to be sheet metal painted gray. As a result of the penetrations being sealed with non-rated material, the required ceiling/floor assembly rating is not achieved.

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 corridor doors close and latch properly into their frames. There shall be no impediment to closing the door, only approved hold open devices may be used.

THE FINDINGS INCLUDE:

- During the morning hours of 3/12/13 while touring the facility, the following items were observed regarding corridor doors:

1) Three (3) of the doors to the on call rooms within the Emergency Room did not latch into the frames. The striker plates were covered over with tape preventing the doors from achieving positive latching.

2) The set of double doors leading into the patient radiation waiting room are not equipped with a latching mechanism.

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 corridor doors close and latch properly into their frames. There shall be no impediment to closing the door, only approved hold open devices may be used.
Section 19.3.6.3.3 states hold-open devices that release when the door is pushed or pulled shall be permitted. This is further clarified in the A.19.3.6.3.3 (appendix) stating doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 & 3/11/13 while performing the building tour, numerous corridor doors were noted as being deficient, these include but are not limited to the following locations:

1) The second, third and fourth floor levels of the "Wesson" building have corridor doors which double as the room's bathroom door as well. These doors are equipped with manually activated deadbolts (operable from both sides) to secure the doors into their frames when being used as bathroom doors. As a result, the doors can not be pulled closed into the corridor frame without manually unlatching the bathroom lock. In addition, if the deadbolt lock is in the extended position with the door in the open position, it acts as a deterrent from closing & latching the door into the frame.
Note: The deadbolts can't be extended into the corridor frames as there are no openings in the jambs for the throw latch bolt.

2) The "East" building 's patient care floor levels corridor doors are obstructed from closing due to trash barrel containers. These containers which are approximately 10" in depth are placed against a wall adjacent to the doors with an approximate 6" depth. As a result, the doors hit the containers, pushing them against the door jambs, preventing the doors from closing.
Note: The facility relocated some of these trash containers during survey.

3) The Anesthesia Office corridor door, labeled #1842, is equipped with a kick stop device preventing the door from closing as required.

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 smoke barrier doors are maintained as required.

THE FINDINGS INCLUDE:

- During the morning hours of 3/4/13 while touring the facility, it was observed that the fifth floor level smoke barrier door, located at the connector of the "Daly" Building, does not close as required. The door hits the top jamb preventing the door from sitting into the side jambs as designed.

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 exit passageways are maintained as required.
Section 7.2.6.2 states an exit passageway shall be separated from other parts of the building as specified in 7.1.3.2.
Section 7.1.3.2.1 states:
(b) The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.

THE FINDING INCLUDE:

- During the afternoon hours of 3/12/13 while touring the facility, it was observed that the door to the Gown Room (B 1015) located within the exit passage in the basement level has had the closing device disconnected. This door is part of the 2-hour rated exit passage and is required to be equipped with a self closing device.
Note: The Mass Mutual Building is 8-stories in height.

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 3/4/13 while touring the facility, it was observed that the fifth floor level "F" stairwell door is removed. As a result of the missing 90-minute labeled door, the Psychiatric Unit door, equipped with a 45-minute label, is now serving as the stairwell enclosure. Thus the stairwell rating is reduced from the required two hour fire resistance rating to a 45-minute 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. Section 7.2.2.3.2 states stairs shall have landings at door openings. Stairs and intermediate landings shall continue with no decrease in width along the direction of egress travel.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, the following items were observed regarding stairwells:

1) The following stairwells are not constructed with the minimum 44" clear width:
a) Stairwell "A" is 41" in width
b) Stairwell "B" is 37" in width
c) Stairwell "C" is 38" in width
d) Stairwell "D" is 41" in width
e) Stairwell "E" is 41" in width
f) Stairwell "F" is 41" in width
g) Stairwell "G" is 38" in width
In addition, many of these stairwells have radiators located at various landings reducing the travel width to less than 37" in numerous locations.

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 egress stairwells are properly designed & maintained. Section 7.7.3 states the exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/12/13 while touring the facility, it was observed that stairwells: "J"; #1 and #5 continue three (3) levels below the level of exit discharge. The stairs on the first and second floor levels are not equipped directional devices indicating that the level of discharge was in the upward direction.

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 maximum travel distances to exit egress locations are not exceeded. Section 19.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 100 ft (30 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 150 ft (45 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.4 states the travel distance between any point in a suite of sleeping rooms as permitted by 19.2.5 and an exit access door of that suite shall not exceed 100 ft (30 m) and shall meet the requirements of 19.2.6.2.2.
Section 19.2.5.6 states suites of sleeping rooms shall not exceed 5000 ft2 (460 m2).
Section 19.2.5.7 states suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2 (930 m2).
Section 19.2.5.8 suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 ft (30 m) and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 ft (15 m).

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/5/13 while touring the facility, the following items were observed:
1) The overall distance from Suite 1 to the nearest exit is 215'. The total allowable travel distance is 200' in a fully sprinklered building. In addition, as the floor plans do not specify 2-hour fire separations between buildings, and not all the buildings are equipped with a complete automatic sprinkler system, the additional 50' of additional travel distance can not be applied.
Note: This suite originally would have met the travel distance but a door which shows as still existing on the supplied floor plans has since been removed. With the removal of this door, the distance was increased dramatically as the other door exited to another corridor.

2) The patient room corridor doors #3425 and #3426 on the third floor level of the "East" Building are approximately 115' from the nearest exit door. (Please refer to ID Prefix Tag K056)

3) As noted in the initial comments K00, the facility submitted an "equivalency" letter for review for the oversized sleeping and non-sleeping suites. As stated, CMS requires an FSES to be performed to be deemed equivalent to the LSC. These suites and deficient issues are noted in the following locations:

a) Cardiac Surgery Intensive Care Unit (CSICU): sleeping suite listed as 10,282 square feet (sf)
b) Neonatal Intensive Care Unit (NICU): sleeping suite listed as 7,325 square feet (sf)
c) Continuing Care Nursery (CCN): no direct exit to a corridor
d) Operating Suite: non-sleeping suite listed as 20,394 square feet (sf) with a travel distance of 161 feet exceeding the allowable distance of 100 feet.

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

Based on observations and confirmed by staff, the facility failed to ensure egress doors are maintained as required. Section 7.2.1.5.1 states doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/12/13 while touring the facility, it was observed that the Davis Family Waiting area has a door with an exit sign located directly above. When the door was checked for operation, it was found to be in the locked position and only operable by key.
Note: Although this door is not a required exit door as multiple exits are provided within that location, the door is equipped with an exit sign signifying it is a means of egress.

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

Based on observations and confirmed by staff, the facility failed to ensure egress doors are maintained as required. Section 7.2.1.5.1 states doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/6/13 while touring the facility, it was observed that the third floor level connector which leads into the Medical Office Building has a set of double doors equipped with magnetic locking devices. The doors were observed in the locked position at the time of survey, and are not equipped with any type of override device for the locks' release. In addition, there is an exit sign located directly above the doors indicating that this is a means of egress from the connecting corridor.

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

Based on observations and confirmed by staff, the facility failed to ensure doors provided are of the proper width. Section 19.2.3.5 states the minimum clear width for doors in the means of egress shall be not less than 32 in. (81 cm) wide.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/6/13 while touring the facility, it was observed that the doors located on the first floor level of the "Wright" Building's office area are 30 inches wide.

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

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/6/13 while touring the facility, it was observed that the door, labeled # 3131, and part of the two hour fire rated barrier, did not close and latch as required. The door hit the top jamb preventing positive latching when released form the open position.

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

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/6/13 while touring the facility, it was observed that the third floor level connector which leads into the Medical Office Building has a set of double doors which also act as a 2-hour horizontal exit. When tested for operation, one of these doors would not latch in the closed position.

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 egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

- During the morning hours of 3/6/13 while performing the building tour, it was observed that light switches are mounted in the "S-Link" corridor and the "S-Link" stairwell which are accessible to staff, patients and visitors. When the switches were tested for operation, the entire corridor as well as the stairwell are not provided with the required illumination.

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 egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, it was observed that light switches are mounted in the main corridors and stairwells accessible to staff, patients and visitors. When the switches were tested for operation, the entire corridor as well as the stairwell are not provided with the required illumination. This was observed throughout the hospital.

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

Based on observations and confirmed by staff, exit signs are not provided as required. Section 7.10.1.2 states exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, exits shall be marked by an approved sign readily visible from any direction of exit access.

THE FINDINGS INCLUDE:

- During the morning hours of 3/6/13 while performing the building tour, it was observed that exit signs, on the seventh floor level rear area, are not installed as required. The following items were observed regarding exit signs:

1.) One of the exit signs is missing a directional arrow indicating that a turn is required to egress towards the exit stairwell.
2) One of the exit signs is facing the wrong direction, directing egress travel away from the egress stairwell.

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

Based on observations and confirmed by staff, exit signs are not provided as required. Section 7.10.1.2 states exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

THE FINDINGS INCLUDE:

- During the morning hours of 3/4/13 while performing the building tour, it was observed that exit sign on the fifth floor level Adult Psychiatric Unit is one sided. The sign does not specify the direction of travel to the stairwell from both directions as required.

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

Based on observations and confirmed by staff, manually operated fire alarm boxes (pull stations) are not installed as required. NFPA 72 section states each manual fire alarm box shall be securely mounted. The operable part of each manual fire alarm box shall be not less than 3-1/2 ft (1.1 m) and not more than 4-1/2 ft (1.37 m) above floor level.
Section 2-8.2.1 states manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.
Section 2-8.2.2 states manual fire alarm boxes shall be located within 5 ft (1.5 m) of the exit doorway opening at each exit on each floor.
Section 2-8.2.3 states manual fire alarm boxes shall be mounted on both sides of group openings over 40 ft (12.2 m) in width. Manual fire alarm boxes shall be mounted within 5 ft (1.5 m) of each side of the opening.
Section 2-8.2.4 states additional manual fire alarm boxes shall be provided so that the travel distance to the nearest fire alarm box will not be in excess of 200 ft (61 m) measured horizontally on the same floor.

THE FINDINGS INCLUDE:

- During the afternoon hours of 3/12/13 while touring the facility, it was observed that the manual fire alarm boxes (pull stations) on the third floor level are located at a distance of 240' apart from each other.

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

Based on observations and confirmed by staff, manually operated fire alarm boxes (pull stations) are not installed as required. NFPA section 72 2-8.1 states each manual fire alarm box shall be securely mounted and the operable part of each manual fire alarm box shall be not less than 3-1/2 ft (42") and not more than 4-1/2 ft (54") above floor level.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, it was noted that manually operated fire alarm boxes (pull stations) are mounted at heights of 60 inches from the floor throughout the facility. These locations include but are not limited to each floor level of the "East" building.

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 smoke detectors are installed as required. NFPA 72 section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, smoke detectors were observed as being located closer than three feet (3') from a supply/return air diffuser. The detectors include but are not limited to the following locations:

1) Second floor level East Building Waiting Room
2) Third floor level North Building corridor

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

During the weeks of 3/4/13 and 3/11/13 while performing the building tour, the following items but not limited to were observed regarding the automatic sprinkler system:

Based on observations and confirmed by staff, sprinklers are not provided in all locations as required. 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. This facility is required to be fully sprinklered to meet the numerous exceptions which are utilized by installation of the automatic sprinkler system.
NFPA 13 section 5-13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states 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.
Section 4.6.12.1 requires any device, equipment, system, condition, arrangement, level of protection, or any other feature that is required for compliance with the provisions of the LSC to be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

" Central Sprinkler Co. " model GB20 sprinkler heads manufactured from 1989 to 2000 have been determined to be defective and must be replaced.

THE FINDINGS INCLUDE:

1) The patient rooms on the third floor level of the "East" Building are not protected by the automatic sprinkler system. As a result, the 50 feet of additional travel distance allowable (for a building equipped with a complete automatic sprinkler system) can not be utilized. Therefore, the corridor doors to patient room(s) #3425 & #3426 exceed the allowable 100 feet of travel distance. These doors are approximately 115' from the nearest exit door. (Please refer to ID Prefix Tag K036)

2) The non-sprinklered third floor level electrical room, #S3400S, is not separated by a 2-hour fire rated construction. The room is currently equipped with a non-rated door.

3) "Star Sprinkler Corporation" model G-20 recalled sprinkler heads are installed in the following areas:
- Daly Building's Atwater café
- first floor level Operating Room Suite
- Springfield Building's corridor and offices on the fifth floor level Psychological Unit.

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

Based on record review and staff interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure reading.

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 sprinkler heads are maintained as required. NFPA 25 section 2.2.1.1 requires sprinklers to be free of corrosion, foreign material, paint, and physical damage. Any sprinkler shall be replaced that is painted, corroded damaged, or loaded.
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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

The following items were noted during survey conducted 3/4/13 through 3/14/13:

1.) Several recessed sprinkler heads located behind the serving line of the cafeteria are painted with ceiling paint.

2) Record review of the quarterly automatic sprinkler system records available on revealed that there is no documentation of the alarm valve having been inspected internally in the past 5 years for the Wason 800 Building, Wason 700 Building (North Wing) and the Daly Building.

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

Based on observations, the facility did not ensure that portable electric heaters are prohibited from the building.
Section 9.7.8 states portable space-heating devices shall be prohibited in all health care occupancies.

THE FINDING INCLUDE:

- Observations while touring the facility on 3/6/13 at 10:00 A.M. revealed a portable electric heater in the second floor level Operating Room Services Coordinator's Room, labeled room # CH2050.

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 cylinders are properly secured. NFPA 99 section 8-3.1.11.2 (h) requires cylinder storage to meet the requirements of 4-3.5.2.1(b) 27 which states free-standing cylinders must be properly chained or supported in a stand or cart.

THE FINDINGS INCLUDE:

- Throughout the survey, during the weeks of 3/4/13 and 3/11/13, free standing "E" cylinders of oxygen were observed throughout the hospital's Main Building and Mass Mutual Building, typical of the free standing "E" cylinder observed in the penthouse (on 3/6/13) outside of the heli-pad area.

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 cylinders are properly secured. NFPA 99 section 8-3.1.11.2 (h) requires cylinder storage to meet the requirements of 4-3.5.2.1(b) 27 which states free-standing cylinders must be properly chained or supported in a stand or cart.
NFPA 99 section 4.3.1.1.2 (4) states the electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

THE FINDINGS INCLUDE:

- During the weeks of 3/4/13 and 3/11/13 while performing the building tour, the following items were observed regarding the storage of oxygen cylinders:

1) Several "E-cylinders" of oxygen were found free standing in various locations. These include but are not limited to the following locations:
-Fifth floor level Daly Building's Clean Utility Room
- Room S3500A (Nurse Conference Room)

2) The third floor level Oxygen Storage Room C3329A contains over 3000 cubic feet of stored oxygen. The room has a light switch mounted at 48" above the floor height. Note: Because of the amount of cylinders located around the perimeter of the room, it could not be determined if the room also had wall receptacles located behind the oxygen cylinders.

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

Based on observations, the facility failed to ensure the bulk oxygen tank is maintained in accordance with NFPA 50. Sections 2.2.1 and 2.2.1.12 require the minimum distance between any bulk oxygen storage container and any sidewalk or parked vehicle to be at least 10 feet.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning of 3/6/13 at 11:00 A.M. revealed that cars are parked within eight feet of the bulk oxygen tank.

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

Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1.
NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters.
Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.
Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.
Section 2.3.2 requires pressure gauges to be replace or tested every 5 years.
Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.
NFPA #13, section 4-1.1 states, a listed pressure gauge conforming to 5-15.3.2 shall be installed in each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.


THE FINDINGS INCLUDE:

- A review of the records available on 3/12/13 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valves are not operated annually through their full range and returned their normal position.
4. Control valve supervisory (tamper)switches are not tested at least semi-annually.
5. OS&Y are not lubricated annually.
6. The facility does not have documentation substantiating that the pressure gages have been tested or calibrated in the last 5 years.
7. The facility does not have documentation substantiating that the alarm valve has been internally inspected in the last 5 years.
8. The was no pressure gauge present above and below the sprinkler system check valve.

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 exit egress routes are properly maintained. Section 7.1.10.1 states means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the morning of 3/11/13, at 10:00 A.M. revealed that three of the exits, including two (2) from the library and one (1) from the Recovery Pad do not discharge to a public way.

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

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Based on observations and confirmed by staff, the facility failed to assure that all sprinkler valves are electrically supervised.

THE FINDINGS INCLUDE:

- The Post Indicator Valve (P.I.V.) located on the supply side of the automatic sprinkler system is not electrically supervised to the fire alarm system. The P.I.V. valve is located outside the building between the Chestnut Building and the Power Plant.

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

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Based on record review the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required. 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.
Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.

THE FINDINGS INCLUDE:

- Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure readings.

- Record review of the quarterly automatic sprinkler system records available on 3/6/13 revealed that there is no record of the alarm valve having been inspected internally in the past 5 years for the wet and dry system for the Chestnut building.

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

Based on record review and staff interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

- Record review and interview with a facilities supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure reading.

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. 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

- Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of monthly automatic sprinkler pressure readings.

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

Based on observations and confirmed by staff, sprinklers are not provided in all locations as required. Section 21.1.6.3 states buildings of two or more stories in height housing ambulatory health care facilities shall be of Type I(443), Type I(332), Type II(222), Type II(111), Type III(211), Type IV(2HH), or Type V(111) construction. (See 8.2.1.)
Exception: Buildings constructed of Type II (000), Type III (200), or Type V(000), if protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. This facility is required to be fully sprinklered as it is of Type II (000) construction. NFPA 13 section 5-13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states 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.
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 hours of 3/13/13 while performing the building tour, it was observed that the electrical rooms are not protected by automatic sprinkler system. These rooms contain numerous ducts which penetrate the 2-hour fire rated walls. The ducts do not have access panels on either side of the walls to determine if fire dampers are installed within the ductwork as required.

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

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Based on observations and confirmed by staff, stairwells are not maintained as required. Section 21.3.1 states protection of vertical openings shall be in compliance with section 8.2.5. Section 8.2.5.1 states every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation.

THE FINDINGS INCLUDE:

- During the morning hours of 3/13/13 while performing the building tour, it was observed that the stairwell door labeled #2032 does not latch when in the closed position. It was noted that the electronic door strike was malfunctioning preventing positive latching from occurring.

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

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Based on observation and confirmed by staff, the facility failed to provide two conforming smoke compartments as required. Section 21.3.7.2 states ambulatory health care facility shall be divided into not less than two smoke compartments.

THE FINDINGS INCLUDE:

- During the morning hours of 3/13/13 while performing the building tour, it was observed that the facility did not provide a conforming smoke barrier on the 1st and 2nd floors of the building. According the building floor plans provided, the 1st floor is 29,803 square feet (sf.) in size, and the 2nd floor is 25,167 sf. in size.

NOTE: As noted in the initial comments K00 in Bldg #01, the facility submitted an "equivalency" letter for review for various deficiencies identified by the hospital prior to survey. An equivalency was also provided for the lack of smoke barriers in building #04. As stated, CMS requires an FSES to be performed to be deemed equivalent to the LSC.

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

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Based on record review the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by 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. Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

- Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure readings.

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

Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1.
NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters.
Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.
Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.
Section 2.3.2 requires pressure gauges to be replace or tested every 5 years.
Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.
NFPA #13, section 4-1.1 states, a listed pressure gauge conforming to 5-15.3.2 shall be installed in each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.


THE FINDINGS INCLUDE:

- A review of the records available on 3/12/13 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valves are not operated annually through their full range and returned their normal position.
4. Control valve supervisory (tamper) switches are not tested at least semi-annually.
5. OS&Y are not lubricated annually.
6. The facility does not have documentation substantiating that the pressure gages have been tested or calibrated in the last 5 years.
7. The facility does not have documentation substantiating that the alarm valve has been internally inspected in the last five (5) years.
8. The was no pressure gauge present below the sprinkler system check valve.
9. Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure readings.



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

Based on record review and confirmed by staff, the facility failed to assure that the automatic sprinkler system is maintained and inspected as required by LSC Section 4.6.12.1.
NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters.
Section 2.3.3.1 requires alarm devices on wet pipe systems to be tested at least quarterly by opening the inspectors test connection.
Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
Section 9.3.4.1 requires each control valve to be operated annually through its full range and returned to its normal position.
Section 9.3.4.3 requires valve supervisory switches to be tested at least semi-annually.
Section 9.3.5 requires the operating stems of outside screw and yoke valves (OS&Y) to be lubricated annually.
Section 2.3.2 requires pressure gauges to be replace or tested every 5 years.
Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years.
NFPA #13, section 4-1.1 states, a listed pressure gauge conforming to 5-15.3.2 shall be installed in each system riser. Pressure gauges shall be installed above and below each alarm check valve where such devices are present.
NFPA 25 section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly.

THE FINDINGS INCLUDE:

- A review of the records available on 3/12/13 revealed that maintenance testing and inspection of the automatic sprinkler system is performed annually. The following deficiencies were observed:
1. The flow switch is not tested at least quarterly by opening the inspectors test connection.
2. The sprinkler system pressure gauge is not inspected monthly.
3. Control valves are not operated annually through their full range and returned their normal position.
4. Control valve supervisory (tamper) switches are not tested at least semi-annually.
5. OS&Y valves are not lubricated annually.
6. The facility does not have documentation substantiating that the pressure gages have been tested or calibrated in the last 5 years.
7. The facility does not have documentation substantiating that the alarm valve has been internally inspected in the last 5 years.
8. The was no pressure gauge present above and below the sprinkler system check valve.
9. Record review and interview with a Facilities Supervisor on the morning of 3/13/13 revealed that there is no record (s) of a monthly or weekly water pressure readings.

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