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Based on observations and interviews during the survey, the facility failed to maintain the facility in good repair.

Findings:

VALENTINE HALL

a) On 07/08/15 at approximately 9:43AM, a brown stained ceiling tile was noted in the NW2 Unit Day Room.

b) On 07/08/15 at approximately 10:51AM, a brown stained ceiling tile was noted in the corridor in the vicinity of the SE2 Unit Medication Room.

c) On 07/08/15 at approximately 12:06PM, brown splatter marks were noted on the ceiling in the SE1 Unit Day Room.

d) On 07/08/15 at approximately 12:55PM, two (2) brown stained ceiling tiles were noted in the corridor between the Main Lobby and the NW1 Unit.

e) On 07/08/15 at approximately 12:56PM, a black colored stain was noted on the ceiling around a concealed sprinkler head in the Main Lobby.


JENNINGS HALL

f) On 07/09/15 at approximately 9:00AM, two (2) brown stained ceiling tiles were noted in the corridor between rooms 217 and 220 on the 2nd Floor.

g) On 07/09/15 at approximately 9:20AM, two (2) brown stained ceiling tiles were noted in the corridor in the vicinity of Room 205 on the 2nd Floor.

In an interview on 07/09/15 at approximately 9:00AM, the Director of Engineering stated that regular rounds are made and stained ceiling tiles are replaced when seen.

42CFR482.41 (a)
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Based on observations and interviews, the facility did not ensure that the Life Safety from Fire requirements were met.

Findings:

VALENTINE HALL

Based on observations and interviews during the survey, unsealed vertical penetrations were noted in rooms in the Basement.

Findings:

On 07/08/15 between 2:00PM - 3:00PM, multiple unsealed vertical penetrations were noted through the ceilings of the Engineering Storage Room and the Maintenance Shop in the Basement.

In an interview on 07/08/15 at approximately 3:05PM, the Director of Engineering acknowledged the findings.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5.2


Based on observations and interviews during the survey, the facility failed to ensure that smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating in that a duct containing a motorized fire / smoke damper was found to have been improperly sealed with fire-stopping material.

Findings:

On 07/08/15 at approximately 12:30PM, a duct penetration in the smoke barrier wall between Unit SE1 and Administration that contained a motorized fire / smoke damper was found to have been improperly sealed with fire-stopping materials. Intumescing fire-stopping materials expand when exposed to heat and would impinge on the ducts, possibly crushing the ducts, and could prevent the fire / smoke damper from operating properly.

In an interview on 07/08/15 at approximately 12:30PM, the Director of Engineering acknowledged the findings.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.7.3


JENNINGS HALL

Based on observations and interviews during the survey, the facility failed to ensure that smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating in that: 1) unprotected steel beams were noted incorporated as part of the smoke barrier walls on the 1st and 2nd Floors, and 2) an unfinished wall assembly, top of wall joint filled with mineral wool but not fire-stopped, was noted on the 2nd Floor.

Findings:

On 07/09/15 between 8:00AM - 11:30AM, smoke barrier walls were not constructed to have at least a one-half (½) hour fire resistance rating. The following examples were noted:

1) Unprotected steel beams were observed incorporated as part of the smoke barrier walls on the 1st and 2nd Floors. This was noted above the ceilings within the Case Coordinator'S Office on the 2nd Floor and above the cross-corridor smoke barrier doors in the West Wing on the 1st Floor.

2) An unfinished wall assembly was observed above the cross-corridor smoke barrier doors in the West Wing on the 2nd Floor. The top of wall joint was filled with mineral wool but lacked an approved UL-listed fire-stopping material.

In an interview on 07/09/15 at approximately 9:10AM, the Director of Engineering acknowledged the findings.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.3.7.3


VALENTINE HALL

Based on observations and interviews during the survey, the facility failed to ensure that Exit Enclosures (such as stairways) are enclosed with construction having a fire resistance rating of at least one (1) hour. This was noted for stairs on the 1st Floor.

Findings:

On 07/08/15 between 11:45AM - 1:00PM, the facility failed to ensure that Exit enclosures were enclosed with construction having a fire resistance rating of at least one (1) hour and provide protection against fire or smoke from other parts of the building. Unprotected steel beams were observed incorporated as part of the stair enclosures of the SW1 and NW1 stairs.

In an interview on 07/08/15 at approximately 11:47AM, the Director of Engineering stated that the facility will check the other stairs and address.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1


JENNINGS HALL

Based on observations and interviews during the survey, the facility failed to ensure that Exit enclosures (such as stairways) are enclosed with construction having a fire resistance rating of at least one (1) hour. This was noted for stairs on the 1st and 2nd Floors and the Basement.

Findings:

On 07/09/15 between 9:00AM - 11:30AM, the facility failed to ensure that Exit enclosures were enclosed with construction having a fire resistance rating of at least one (1) hour and provide protection against fire or smoke from other parts of the building. Examples are:

1) Unprotected steel beams were observed incorporated as part of the Stair enclosures of the West and Center Stairs on the 1st Floor, the East Stair on the 2nd Floor and the Center Stair in the Basement.

2) Multiple unsealed penetrations were observed in the Center Stair on the 2nd Floor and an unfinished wall assembly, the top of wall joint was filled with mineral wool but lacked an approved UL-listed fire-stopping material, was observed in the East Stair on the 1st Floor.

In an interview on 07/09/15 at approximately 10:46AM, the Director of Engineering stated that the facility may request a Time Limited Waiver.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1


VALENTINE HALL

Based on observations and interviews during the survey, the facility failed to ensure that Exit access is so arranged that Exits are readily accessible at all times in accordance with Section 7.1 in that the outer set of power sliding doors at the Admitting Entrance had a thumb turn locking device.

Findings:

On 07/08/15 at approximately 12:40PM, the outer set of power sliding doors at the Admitting Entrance had a thumb turn locking device, that when engaged, would prevent the doors from breaking away during a loss of power.

In an interview on 07/08/15 at approximately 12:40PM, the Director of Engineering stated that he would disable the lock.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 7.1


JENNINGS HALL

Based on observations and interviews during the survey, the facility failed to ensure that emergency illumination was arranged so that there would not be a delay of more than ten (10) seconds when changing from the normal power source to the emergency power source. This was noted at the Exit discharge locations for two (2) of three (3) Exit Stairs.

Findings:

On 07/09/15 between 9:30AM - 10:30AM, the Exit discharge locations from two (2) of three (3) Exit Stairs were observed to be arranged with High Intensity Discharge (HID) lighting fixtures. The standard HID lighting fixture takes more than ten (10) seconds to start once they are energized. Examples are:

1) A single bulb HID lighting fixture was observed at the Exit discharge from the West Stair.

2) Two (2) single bulb HID lighting fixtures were observed at the Exit discharge from the East Stair.

In an interview on 07/09/15 at approximately 9:45AM, the Director of Engineering acknowledged the findings.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 7.9.1.2


VALENTINE HALL

Based on interview and documentation review during the survey, the facility failed to ensure that the smoke alarm system in the building was maintained, inspected and tested in accordance with the requirements of NFPA 72 in that the facility could not provide documentation of recent sensitivity tests conducted on the smoke detectors.

Findings:

On 07/09/15 at approximately 1:30PM, the facility Smoke Alarm System Maintenance Records were reviewed. There was no documentation provided at this time regarding the last smoke detector sensitivity testing.

In an interview on 07/09/15 at approximately 1:30PM, the Director of Engineering stated that he was unable to find documentation for the last sensitivity test.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.6.1.4, NFPA 72-1999: 7-3.2.1


JENNINGS HALL

Based on interview and documentation review during the survey, the facility failed to ensure that the smoke alarm system in the building was maintained, inspected and tested in accordance with the requirements of NFPA 72 in that the facility could not provide documentation of recent sensitivity tests conducted on the smoke detectors.

Findings:

On 07/09/15 at approximately 1:31PM, the facility Smoke Alarm System Maintenance Records were reviewed. The documentation indicated that the most recent sensitivity test was completed on 06/25/09. There was no documentation provided at this time of a more recent sensitivity testing.

In an interview on 07/09/15 at approximately 1:31PM, the Director of Engineering stated that he was unable to find documentation for a more recent sensitivity test.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.6.1.4, NFPA 72-1999: 7-3.2.1


VALENTINE HALL

Based on observations and interviews during the survey, the facility failed to ensure that required automatic sprinkler systems were continuously maintained in reliable operating condition. This was noted on the 1st and 2nd Floors and the Basement.

Findings:

On 07/08/15 between 9:30AM - 3:30PM, the automatic sprinkler system was noted not being continuously maintained in reliable operating condition. Examples include but are not limited to:

1) Missing sprinkler caps / escutcheons.

a. Two (2) missing concealed sprinkler caps within the NW2 Stair.

b. A missing concealed sprinkler cap in the Housekeeping Office on Unit SE2 on the 2nd Floor.

c. A missing concealed sprinkler cap in the corridor in the vicinity of the Housekeeping Closet on Unit SW2 on the 2nd Floor.

d. Seven (7) missing concealed sprinkler caps in the Medical Records Storage Room in the Basement.

2) Painted sprinkler caps.

a. One (1) painted concealed sprinkler cap in the Bathroom across from the Day Room on Unit SW2 on the 2nd Floor.

b. One (1) painted concealed sprinkler cap outside of the Medication Room on Unit SW1 on the 1st Floor.

c. Two (2) painted concealed sprinkler caps in the Main Lobby on the 1st Floor.

d. Two (2) painted concealed sprinkler caps within the stairwell in the vicinity of the Main Lobby.

In an interview on 07/08/15 at approximately 1:36PM, the Director of Engineering stated that the facility would address the issues immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.7.5, 1998 NFPA 25: 2-2.1.1


Based on observations and interviews during the survey, the facility failed to ensure that required automatic sprinkler systems were continuously maintained in reliable operating condition. This was noted in the Basement.

Findings:

On 07/08/15 at approximately 3:11PM, it was noted that a minimum of two (2) sprinklers of each type and temperature rating installed were not provided. The facility lacked two (2) spare pendent type sprinkler heads and two (2) high temperature upright type sprinkler heads. This was noted at the sprinkler main pipe in the Basement.

In an interview on 07/08/15 at approximately 3:11PM, the Director of Engineering stated that he worked on a spare sprinkler inventory list for the campus and will order these spare heads immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.7.5, 1998 NFPA 25: 2-4.1.4


JENNINGS HALL

Based on observations and interviews during the survey, the facility failed to ensure that required automatic sprinkler systems were continuously maintained in reliable operating condition. This was noted on the 1st and 2nd Floors.

Findings:

On 07/09/15 between 8:45AM - 11:30AM, the automatic sprinkler system was noted not being continuously maintained in reliable operating condition. Examples include but are not limited to:

1) Missing sprinkler caps / escutcheons.

a. One (1) missing concealed sprinkler cap in the corridor outside of the West Stair on the 2nd Floor.

b. Two (2) missing concealed sprinkler caps in the corridor in the vicinity of Room 107 on the 1st Floor.

c. A missing concealed sprinkler cap in the corridor outside of the East Stair on the 1st Floor.

In an interview on 07/09/15 at approximately 9:55AM, the Director of Engineering stated that the facility will address the issues immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.7.5, 1998 NFPA 25: 2-2.1.1


Based on observations and interviews during the survey, the facility failed to ensure that required automatic sprinkler systems were continuously maintained in reliable operating condition. This was noted in the Basement.

Findings:

On 07/09/15 at approximately 11:15AM, it was noted that a minimum of two (2) sprinklers of each type and temperature rating installed were not provided. The facility lacked two (2) spare concealed type sprinkler heads and two (2) sidewall type sprinkler heads. This was noted at the sprinkler main pipe in the Basement.

In an interview on 07/09/15 at approximately 11:15AM, the Director of Engineering stated that he will order these spare heads immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.7.5, 1998 NFPA 25: 2-4.1.4


Based on observations, interviews and documentation review during the survey, the facility failed to ensure that required automatic sprinkler systems were continuously maintained in reliable operating condition.

Findings:

On 07/09/15 at approximately 11:17AM, a date of 05/15/10 was noted on the pressure gauges on the sprinkler main pipe. In an interview with the Director of Engineering at this time, he stated that the date was when the gauges were last replaced. Gauges shall be replaced every five (5) years or tested every five (5) years by comparison with a calibrated gauge.

In an interview on 07/09/15 at approximately 11:17AM, the Director of Engineering stated that he will have the gauges replaced immediately.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.7.5, 1998 NFPA 25: 2-3.2, 9-4.2.1


JENNINGS HALL

Based on observations and interviews during the survey, the facility failed to ensure that heating, ventilating, and air conditioning shall comply with Section 9.2. This was noted on the 1st and 2nd Floors.

Findings:

On 07/09/15 between 8:45AM - 11:30AM, the interstitial space above the ceiling in the egress corridors on the 1st and 2nd Floors was observed being used as a plenum. Examples include, but are not limited to, non-ducted air transfer openings observed above the suspended ceiling in the walls above:

1) 1st and 2nd Floor Case Coordinator's Office

2) 1st and 2nd Floor Group Room A.

3) 1st and 2nd Floor Pantry.

4) An approximately one (1) foot by two (2) foot non-ducted air transfer opening in the drop ceiling on either side of the Medication Room door in the vicinity of the 2nd Floor Nurses' Station.

In an interview on 07/09/15 at approximately 9:57AM, the Director of Engineering stated that the facility will address the issue.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 9.2.1, 1999 NFPA 90A: 2-3.11.1


VALENTINE HALL

Based on observations and interviews during the survey, the facility failed to ensure that not more than ten (10) gallons of alcohol based hand sanitizer were stored in a single smoke compartment outside a Storage Cabinet. This was noted in the Materials Storage / Paper Goods Room in the Basement.

Findings:

On 07/08/15 at approximately 2:25PM, greater than ten (10) gallons of alcohol based hand sanitizer (Ethyl Alcohol 70%) was noted being stored in the Materials Storage / Paper Goods Room in the Basement and not within a Storage Cabinet.

In an interview on 07/08/15 at approximately 2:25PM, the Director of Engineering stated that the facility will get a fire-rated cabinet immediately.

CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623


JENNINGS HALL

Based on observations and staff interview during the survey, Alcohol Based Hand Rub (ABHR) dispensers were noted installed above: 1) an ignition source, and 2) above carpet in a building that is not fully sprinklered. This was noted on two (2) of two (2) floors.

Findings:

On 07/09/15 between 9:30AM - 11:30AM, ABHR dispensers were noted installed improperly in the following areas:

1) Directly above an ignition source. Examples are:

a. An ABHR dispenser installed directly above a light switch located within the 2nd Floor Medication Room.

b. An ABHR dispenser installed directly above an electrical outlet in the 1st Floor corridor in the vicinity of the Soiled Utility Room.

2) An ABHR dispenser located in the corridor in the vicinity of the 1st Floor Nurses' Station was observed installed directly above carpet. The building is not fully sprinklered as evidenced by areas lacking sprinkler coverage including but not limited to the roof landings of the East and West Stairs.

In an interview on 07/09/15 at approximately 9:31AM, the Director of Engineering stated that he will have the ABHR dispensers relocated immediately.

CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623


JENNINGS HALL

Based on observations and interviews during the survey, the facility failed to ensure that the Elevator Machine Room located in the Basement was enclosed in at least one (1) hour fire resistance rated construction.

Findings:

On 07/09/14 at approximately 11:00AM, the Elevator Machine Room located in the Basement was observed not enclosed in at least one (1) hour fire resistance rated construction. Unprotected steel beams were observed incorporated as part of the enclosure and multiple unsealed penetrations were noted around the perimeter of the room.

In an interview on 07/09/15 at approximately 11:00AM, the Director of Engineering acknowledged the findings.

42 CFR 482.41 (b), NFPA 101-2000 Life Safety Code: 19.5.3, 9.4.6
ASME/ANSI A17.1, Safety Code for Elevators and Escalators


VALENTINE HALL

Based on observations and interviews during the survey, the facility failed to provide an NFPA 99 - Health Care Facilities and NFPA 70 - National Electrical Code conforming Type 2 Essential Electrical System (EES) in that Emergency System - Life Safety Branch Wiring was not separated from Critical System Wiring.

Findings:

On 07/09/15 between 8:30AM - 2:30PM, review of the posted Circuit Directories for Emergency Power Panels serving the 1st and 2nd Floors and the Basement indicated that the Panels contained loads from both the Emergency System (ES) and the Critical System (CS). Examples are:

1) Emergency Power Panel "LP-2D" located on the 2nd Floor contained loads from both the Emergency System (Hall Lights) and the Critical System (Receptacles).

2) Emergency Power Panel "LD-1D" located on the 1st Floor contained loads from both the Emergency System (Hall Lights, Outside Lights) and the Critical System (Receptacles, Sanitizing Unit, Coffee Machine).

The facility did not meet all of the exceptions listed in 1999 NFPA 99: 17-3.3.2 in that the facility lacked an automatic battery-powered system that will be effective for at least one and one-half (1½) hours and is otherwise in accordance with NFPA 101, Life Safety Code, and NFPA 70, National Electrical Code, and that will be capable of supplying lighting of at least one (1) ft-candle to Exit Lights, Exit Corridors, Stairways, Nursing Stations, Medication Preparation Areas, Boiler Rooms and Communication Areas. This system must also supply power to operate all alarm systems.

In an interview on 07/09/15 at approximately 2:00PM, the Director of Engineering stated that he will install batteries to serve the life safety loads, like battery pack lights for egress.

42 CFR 482.41 (b), NFPA 99-1999 Standard for Health Care Facilities: 17-3.3.2, 3-5, NFPA 70-1999 National Electrical Code: Articles 517-40


JENNINGS HALL

Based on observations and interviews during the survey, the facility failed to provide an NFPA 99 - Health Care Facilities and NFPA 70 - National Electrical Code conforming Type 2 Essential Electrical System (EES) in that Emergency System - Life Safety Branch Wiring was not separated from Critical System Wiring.

Findings:

On 07/09/15 between 8:30AM - 2:30PM, review of the posted Circuit Directories for Emergency Power Panels serving the 1st and 2nd Floors and the Basement indicated that the Panels contained loads from both the Emergency System (ES) and the Critical System (CS). Examples are:

1) Emergency Power Panel "E3" located at the 2nd Floor Nurses' Station contained loads from the Critical System (Fan Wall Air Conditioners (A/C) Units, Heat Panel, Receptacles). This Panel also fed Emergency Power Panel "LS 2" which contained loads from both the Emergency System (Stair Lights) and the Critical System (Nurse Call, Heat Valves).

2) Emergency Power Panel "E4" located in the 2nd Floor Housekeeping Closet contained loads from both the Emergency System (East and West Building Lights, East and West Pole Lights) and the Critical System (Bedroom A/C, Exhaust Fan, Office A/C).

3) Emergency Power Panel "E2" located at the 1st Floor Nurses' Station contained loads from the Critical System (Fan Wall A/C Units, Unit Heaters, Receptacles). This Panel also fed Emergency Power Panel "LS 1" which contained loads from the Emergency System (Fire Alarm Panel, Stair Lights).

4) Emergency Power Panel "E" located in the Basement Data Center contained loads from both the Emergency System (Fire Alarm, Corridor Lights) and the Critical System (A/C).

The facility did not meet all of the exceptions listed in 1999 NFPA 99: 17-3.3.2 in that the facility lacked an automatic battery-powered system that will be effective for at least one and one-half (1½) hours and is otherwise in accordance with NFPA 101, Life Safety Code, and NFPA 70, National Electrical Code, and that will be capable of supplying lighting of at least one (1) ft-candle to Exit Lights, Exit Corridors, Stairways, Nursing Stations, Medication Preparation Areas, Boiler Rooms and Communication Areas. This system must also supply power to operate all Alarm Systems.

In an interview on 07/09/15 at approximately 2:00PM, the Director of Engineering stated that he will install batteries to serve the life safety loads, like battery pack lights for egress.

42 CFR 482.41 (b), NFPA 99-1999 Standard for Health Care Facilities: 17-3.3.2, 3-5, NFPA 70-1999 National Electrical Code: Articles 517-40