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Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 20 occupants of the facility.

Findings include:

On 09/28/15 at approximately 10:45 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, the fire rated door had holes that penetrated through the door, located in the door to the Kitchen, on the Employee Entrance Corridor.

2. Observed and discussed with the Director of Plant Operations, the door did not close to a positive latch (paper stuffed into door latch), located in Office #6.

3. Observed and discussed with the Director of Plant Operations, the door did not close to a positive latch, located at the West Door to the Dining Room.

Based on observation, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 25 occupants of the facility.

Findings include:

On 09/29/15 at approximately 09:25 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, two (2) incomplete seals on wire penetrations and an unsealed hole in the block wall, located in the smoke rated wall in Main Conference Room.

2. Observed and discussed with the Director of Plant Operations, two (2) unsealed 3"conduits and an incomplete seal on a conduit and wire penetration, located in the smoke rated wall in Fiscal Hallway.

3. Observed and discussed with the Director of Plant Operations, numerous unsealed holes in the block walls, located in the smoke rated walls of the Electrical Room by the Admitting Office.

4. Observed and discussed with the Director of Plant Operations, an incomplete seal on a conduit penetration, located in the smoke rated wall adjacent to Interview Room #2, on A-Unit Main Hall.

5. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration, located in the smoke rated wall above door to Interview Room #2, on A-Unit Main Hall.

6. Observed and discussed with the Director of Plant Operations, an incomplete seal on a conduit with wires, located in the smoke rated wall, located on A-Unit left of the Northwest Group Room.

7. Observed and discussed with the Director of Plant Operations, an incomplete seal on a conduit penetration at the decking, also an incomplete seal on a pipe penetration, located in the smoke rated wall above the door to Room 103, on A-Unit West Bedroom Hall.

8. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration at the decking, located in the smoke rated wall by Room 106, on A-Unit West Bedroom Hall.

9. Observed and discussed with the Director of Plant Operations, an unsealed wire penetration at the decking, located in the smoke rated wall between the Lounge and Room 117, on A-Unit East Bedroom Hall.

10. Observed and discussed with the Director of Plant Operations, an incomplete seal in the block wall, located in the smoke rated wall above the bathroom door, on A-Unit east of the RN Counter.

11. Observed and discussed with the Director of Plant Operations, two (2) unsealed insulated copper pipe penetrations and an unsealed conduit penetration in the smoke rated wall by the Phlebotomy Room, on Main Hall.

12. Observed and discussed with the Director of Plant Operations, two (2) unsealed wire penetrations, gaps in the block wall, and an unsealed conduit in the smoke rated wall, located at the cross corridor smoke barrier doors to the "Back Hall" of B-Unit.

13. Observed and discussed with the Director of Plant Operations, an incomplete seal on a conduit in the smoke rated wall, located above exit by the northwest corner Conference Room, on Unit C-1.

14. Observed and discussed with the Director of Plant Operations, an incomplete seal on conduits and a wire penetration in the smoke rated wall, located at the C-Unit Nurse's Station.

15. Observed and discussed with the Director of Plant Operations, an unsealed hole in the block wall of the smoke rated wall, located by the left Shower Room, on C-Unit.

16. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration and two (2) unsealed copper line penetrations (on the angled wall) in the smoke rated wall, located above Lounge by the C-1 Entrance.

17. Observed and discussed with the Director of Plant Operations, two (2) unsealed wire penetrations in the smoke rated wall, located above both dry erase boards, located on C-Unit Main Hall.

18. Observed and discussed with the Director of Plant Operations, an unsealed conduit (with blue, gray and black wires) in the smoke rated wall, located above the cross corridor smoke barrier doors by Room 316, on D-Unit to North Bedroom Hall.

19. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration at the decking in the smoke rated wall, located in the Exam Room on D-Unit.

Based on observation, the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 12 occupants of the facility.

Findings include:

On 09/28/15 at approximately 11:50 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, the cross corridor smoke barrier door did not close to a positive latch, located at Fire Door #4, on A-Unit.

2. Observed and discussed with the Director of Plant Operations, the cross corridor smoke barrier door did not close to a positive latch, located at Fire Door #8, on B-Unit.

Based on observation, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 9 occupants of the facility.

Findings include:

On 09/28/15 at approximately 10:50 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, the door did not close to a positive latch, located in the Pantry Storage Room, on the Employee Entrance Corridor.

2. Observed and discussed with the Director of Plant Operations, the clothes dryer vent had separated, located in Laundry Room C-2.

3. Observed and discussed with the Director of Plant Operations, the clothes dryer vent piping joints were secured with screws, located in Laundry Room C-1.

4. Observed and discussed with the Director of Plant Operations, the fire rated wall in the Laundry Room does not continue to the decking (contrary to the building plans), an incomplete seal on a black pipe penetration above the entry door to the Laundry Room and an unsealed hole in the block wall above the door to the Exam Room, located in the fire rated wall by Intake Office.

5. Observed and discussed with the Director of Plant Operations, two (2) incomplete seals on an approximate four inch black pipe penetration, also verify the gray/black sealant is fire rated, located in the fire rated wall by entrance into A-Unit.

6. Observed and discussed with the Director of Plant Operations, an incomplete seal on two (2) flexible conduits that penetrate the decking and an unsealed conduit, located in the fire rated wall outside A-Unit Seclusion Hall.

7. Observed and discussed with the Director of Plant Operations, an unsealed conduit in the fire rated wall, approximately one foot west of the cross corridor smoke barrier into the Connector Hallway.

8. Observed and discussed with the Director of Plant Operations, an incomplete seal on an approximate conduit in the fire rated wall, located above the office door, on the southwest corner of the Connector Hallway.

9. Observed and discussed with the Director of Plant Operations, an unsealed large voltage wire penetration in the fire rated wall, located above electrical outlet B-GRO-4 in Room 1D34 (unused Group Room on B-Unit).

10. Observed and discussed with the Director of Plant Operations, an incomplete seal in the block of the fire rated wall, located at Fire Door #9, on Main Hall.

11. Observed and discussed with the Director of Plant Operations, incomplete seals on insulated pipe penetration of the fire rated wall, located in "Kristen's Office".

12. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration in the fire rated wall, located in the HR File Room.

13. Observed and discussed with the Director of Plant Operations, an incomplete seal on a flexible green conduit penetration in the fire rated wall, located above the cross corridor smoke barrier doors from B-Unit into D-Unit.

14. Observed and discussed with the Director of Plant Operations, an unsealed void at the decking in the fire rated wall, located adjacent to the west doors of the New Gymnasium.

Based on observation, the facility failed to provide exit and directional signs in accordance with the LSC section 19.2.10.1. This deficient practice could potentially affect 5 occupants of the facility.

Findings include:

On 09/28/15 at approximately 11:25AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, the exit light was not illuminated, located in the Intake Hallway.

Based on observation, the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect 165 occupants of the facility.

Findings include:

On 09/30/15 at approximately 9:00 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, fire alarm inspection report from Simplex Grinnell noted two (2) deficiencies with the fire alarm system:

a.)The A/V visual failure, located on E-Unit corridor by the Laundry Room.

b.) The L1 Zone, Device 85 did not alarm when tested, device was not wired into the system, located in the S.W. Group Room.

There was no documentation that these issues were corrected at the time of inspection.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect 165 occupants of the facility.

On 09/29/15 at approximately 8:35 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, there was corrosion built up on a battery terminal, located at the "West Unit Generator".

Based on observation, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 15 occupants of the facility.

Findings include:

On 09/28/15 at approximately 10:41 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, there was a trash can stored within three (3) feet of an electrical panel, located in the Copier Room.

2. Observed and discussed with the Director of Plant Operations, there was an electrical extension cord in use, located in the Admitting Office.

3. Observed and discussed with the Director of Plant Operations, there were combustible items stored within three (3) feet of an electrical panel, located in the Janitor's Closet on A-Unit.

4. Observed and discussed with the Director of Plant Operations, there was an electrical extension cord in use, located in the Staff Education Office.

5. Observed and discussed with the Director of Plant Operations, there was an electrical junction box missing a cover plate, located in the Electrical Room by the Admitting Office.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 20 occupants of the facility.

Findings include:

On 09/28/15 at approximately 10:45 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, the fire rated door had holes that penetrated through the door, located in the door to the Kitchen, on the Employee Entrance Corridor.

2. Observed and discussed with the Director of Plant Operations, the door did not close to a positive latch (paper stuffed into door latch), located in Office #6.

3. Observed and discussed with the Director of Plant Operations, the door did not close to a positive latch, located at the West Door to the Dining Room.

Based on observation, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 25 occupants of the facility.

Findings include:

On 09/29/15 at approximately 09:25 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, two (2) incomplete seals on wire penetrations and an unsealed hole in the block wall, located in the smoke rated wall in Main Conference Room.

2. Observed and discussed with the Director of Plant Operations, two (2) unsealed 3"conduits and an incomplete seal on a conduit and wire penetration, located in the smoke rated wall in Fiscal Hallway.

3. Observed and discussed with the Director of Plant Operations, numerous unsealed holes in the block walls, located in the smoke rated walls of the Electrical Room by the Admitting Office.

4. Observed and discussed with the Director of Plant Operations, an incomplete seal on a conduit penetration, located in the smoke rated wall adjacent to Interview Room #2, on A-Unit Main Hall.

5. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration, located in the smoke rated wall above door to Interview Room #2, on A-Unit Main Hall.

6. Observed and discussed with the Director of Plant Operations, an incomplete seal on a conduit with wires, located in the smoke rated wall, located on A-Unit left of the Northwest Group Room.

7. Observed and discussed with the Director of Plant Operations, an incomplete seal on a conduit penetration at the decking, also an incomplete seal on a pipe penetration, located in the smoke rated wall above the door to Room 103, on A-Unit West Bedroom Hall.

8. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration at the decking, located in the smoke rated wall by Room 106, on A-Unit West Bedroom Hall.

9. Observed and discussed with the Director of Plant Operations, an unsealed wire penetration at the decking, located in the smoke rated wall between the Lounge and Room 117, on A-Unit East Bedroom Hall.

10. Observed and discussed with the Director of Plant Operations, an incomplete seal in the block wall, located in the smoke rated wall above the bathroom door, on A-Unit east of the RN Counter.

11. Observed and discussed with the Director of Plant Operations, two (2) unsealed insulated copper pipe penetrations and an unsealed conduit penetration in the smoke rated wall by the Phlebotomy Room, on Main Hall.

12. Observed and discussed with the Director of Plant Operations, two (2) unsealed wire penetrations, gaps in the block wall, and an unsealed conduit in the smoke rated wall, located at the cross corridor smoke barrier doors to the "Back Hall" of B-Unit.

13. Observed and discussed with the Director of Plant Operations, an incomplete seal on a conduit in the smoke rated wall, located above exit by the northwest corner Conference Room, on Unit C-1.

14. Observed and discussed with the Director of Plant Operations, an incomplete seal on conduits and a wire penetration in the smoke rated wall, located at the C-Unit Nurse's Station.

15. Observed and discussed with the Director of Plant Operations, an unsealed hole in the block wall of the smoke rated wall, located by the left Shower Room, on C-Unit.

16. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration and two (2) unsealed copper line penetrations (on the angled wall) in the smoke rated wall, located above Lounge by the C-1 Entrance.

17. Observed and discussed with the Director of Plant Operations, two (2) unsealed wire penetrations in the smoke rated wall, located above both dry erase boards, located on C-Unit Main Hall.

18. Observed and discussed with the Director of Plant Operations, an unsealed conduit (with blue, gray and black wires) in the smoke rated wall, located above the cross corridor smoke barrier doors by Room 316, on D-Unit to North Bedroom Hall.

19. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration at the decking in the smoke rated wall, located in the Exam Room on D-Unit.

Based on observation, the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 12 occupants of the facility.

Findings include:

On 09/28/15 at approximately 11:50 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, the cross corridor smoke barrier door did not close to a positive latch, located at Fire Door #4, on A-Unit.

2. Observed and discussed with the Director of Plant Operations, the cross corridor smoke barrier door did not close to a positive latch, located at Fire Door #8, on B-Unit.

Based on observation, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 9 occupants of the facility.

Findings include:

On 09/28/15 at approximately 10:50 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, the door did not close to a positive latch, located in the Pantry Storage Room, on the Employee Entrance Corridor.

2. Observed and discussed with the Director of Plant Operations, the clothes dryer vent had separated, located in Laundry Room C-2.

3. Observed and discussed with the Director of Plant Operations, the clothes dryer vent piping joints were secured with screws, located in Laundry Room C-1.

4. Observed and discussed with the Director of Plant Operations, the fire rated wall in the Laundry Room does not continue to the decking (contrary to the building plans), an incomplete seal on a black pipe penetration above the entry door to the Laundry Room and an unsealed hole in the block wall above the door to the Exam Room, located in the fire rated wall by Intake Office.

5. Observed and discussed with the Director of Plant Operations, two (2) incomplete seals on an approximate four inch black pipe penetration, also verify the gray/black sealant is fire rated, located in the fire rated wall by entrance into A-Unit.

6. Observed and discussed with the Director of Plant Operations, an incomplete seal on two (2) flexible conduits that penetrate the decking and an unsealed conduit, located in the fire rated wall outside A-Unit Seclusion Hall.

7. Observed and discussed with the Director of Plant Operations, an unsealed conduit in the fire rated wall, approximately one foot west of the cross corridor smoke barrier into the Connector Hallway.

8. Observed and discussed with the Director of Plant Operations, an incomplete seal on an approximate conduit in the fire rated wall, located above the office door, on the southwest corner of the Connector Hallway.

9. Observed and discussed with the Director of Plant Operations, an unsealed large voltage wire penetration in the fire rated wall, located above electrical outlet B-GRO-4 in Room 1D34 (unused Group Room on B-Unit).

10. Observed and discussed with the Director of Plant Operations, an incomplete seal in the block of the fire rated wall, located at Fire Door #9, on Main Hall.

11. Observed and discussed with the Director of Plant Operations, incomplete seals on insulated pipe penetration of the fire rated wall, located in "Kristen's Office".

12. Observed and discussed with the Director of Plant Operations, an unsealed conduit penetration in the fire rated wall, located in the HR File Room.

13. Observed and discussed with the Director of Plant Operations, an incomplete seal on a flexible green conduit penetration in the fire rated wall, located above the cross corridor smoke barrier doors from B-Unit into D-Unit.

14. Observed and discussed with the Director of Plant Operations, an unsealed void at the decking in the fire rated wall, located adjacent to the west doors of the New Gymnasium.

Based on observation, the facility failed to provide exit and directional signs in accordance with the LSC section 19.2.10.1. This deficient practice could potentially affect 5 occupants of the facility.

Findings include:

On 09/28/15 at approximately 11:25AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, the exit light was not illuminated, located in the Intake Hallway.

Based on observation, the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect 165 occupants of the facility.

Findings include:

On 09/30/15 at approximately 9:00 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, fire alarm inspection report from Simplex Grinnell noted two (2) deficiencies with the fire alarm system:

a.)The A/V visual failure, located on E-Unit corridor by the Laundry Room.

b.) The L1 Zone, Device 85 did not alarm when tested, device was not wired into the system, located in the S.W. Group Room.

There was no documentation that these issues were corrected at the time of inspection.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect 165 occupants of the facility.

On 09/29/15 at approximately 8:35 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, there was corrosion built up on a battery terminal, located at the "West Unit Generator".

Based on observation, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 15 occupants of the facility.

Findings include:

On 09/28/15 at approximately 10:41 AM, the following observations were made:

1. Observed and discussed with the Director of Plant Operations, there was a trash can stored within three (3) feet of an electrical panel, located in the Copier Room.

2. Observed and discussed with the Director of Plant Operations, there was an electrical extension cord in use, located in the Admitting Office.

3. Observed and discussed with the Director of Plant Operations, there were combustible items stored within three (3) feet of an electrical panel, located in the Janitor's Closet on A-Unit.

4. Observed and discussed with the Director of Plant Operations, there was an electrical extension cord in use, located in the Staff Education Office.

5. Observed and discussed with the Director of Plant Operations, there was an electrical junction box missing a cover plate, located in the Electrical Room by the Admitting Office.