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Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing, and sealed floor penetrations. This deficiency occurred in 3 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 12:47 pm, observation revealed on the 1st floor in the Smoke Barriers between Yellow Zone and Red Zone, that fire proofing was missing from the structural steel at the smoke barrier up tight to the penthouse floor above. Due to location of the steel beam and height of beam, staff B and the surveyor could not verify the intent of this steel beam. However, at minimum the beam must be protected to at least 1-hour where it penetrates the smoke barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

2. On 03/24/2014 at 2:35 pm, observation revealed on the Basement floor in the Orange Zone-SC, Boiler Room B106, that there was a penetration through the floor that was not fire stopped according to an approved method. The deficiency included a 2 inch diameter hole through the floor assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with ducts in rated walls with fire dampers, and sealed wall penetrations. This deficiency occurred in 4 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 12:40 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Yellow Zone-SC, Penthouse #2, that one or more air ducts penetrated the horizontal floor enclosure and could not be confirmed to have a properly installed fire damper. The duct located in the corner of the room did not have a fire damper and it could not be confirmed if a fire damper was installed to separate this 2-hour floor assembly from the lower levels. All other penetrations through the floor were protected to a 2-hour fire rating, including the penthouse stairwell enclosure. This observed situation was not compliant with NFPA 90A (1999 ed.), sections 3-3.2 or 3-3.3 or 3-3.4.

2. On 03/24/2014 at 3:14 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Orange Zone-SC, Penthouse #1, that one or more air ducts penetrated the horizontal floor enclosure and could not be confirmed to have a properly installed fire damper. The duct located in the corner of the room did not have a fire damper and it could not be confirmed if a fire damper was installed to separate this 2-hour floor assembly from the levels below. All other penetrations through the floor were protected to a 2-hour fire rating, including the penthouse stairwell enclosure. This observed situation was not compliant with NFPA 90A (1999 ed.), section 3-3.2 or 3-3.3 or 3-3.4.

3. On 03/24/2014 at 2:26 pm, observation revealed on the 1st floor in the Orange Zone-SC, Elevator Shaft, from the elevator lobby that penetrations in a vertical shaft were not sealed according to an approved method. The deficiency included a 1 inch hole at a pipe in the shaft. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

4. On 03/24/2014 at 2:40 pm, observation revealed on the Basement floor in the Orange Zone-SC, Elevator Equipment Room, that penetrations in a vertical shaft were not sealed according to an approved method. The deficiency included a 4 inch hole in the wall where the pipe from the elevator equipment penetrated the wall into the elevator shaft. This hole was not there during the last federal survey. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 2:07 pm, observation revealed on the 1st floor in the Orange Zone-SC, Corridor Door at a 2-hour Wall Assembly, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.6 and 8.3.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain hazardous room door assemblies that meet code requirements for doors held-open with the required safe guards. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 2:13 pm, observation revealed on the 1st floor in the Orange Zone-SC, Kitchen Storage Room #1089, that the hazardous room door was prevented from self-closing by a door stop. Hazardous room door had a door closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide enclosures around exit stairs with taped joints on rated walls. This deficiency occurred in 2 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 12:30 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Yellow Zone-SC, Stairwell to Penthouse #2, that the enclosing stairwell walls were not constructed to a 2-hour fire resistance rating because not all of the drywall joints were taped and/or screws covered with drywall compound as required for designs for rated walls. Stairwell enclosure was designed to a 2-hour fire rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4 and 8.2.3.2, and 7.1.3.2.1.

2. On 03/24/2014 at 3:07 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Orange Zone-SC, Stairwell to Penthouse #1, that the enclosing stairwell walls were not constructed to a 2-hour fire resistance rating because not all of the drywall joints were taped and/or screws covered with drywall compound as required for designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4 and 8.2.3.2, and 7.1.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps at the exterior means of egress so the path would be illuminated if any single fixture or bulb failed at egress paths with redundant lighting. This deficiency occurred outside and affected all the interior 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 11:00 am, observation revealed on the 1st floor in the Red Zone-SC, Exit Door #16, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. Egress lighting is required from the exit discharge to the Public Way or 50'-0", whichever is shorter. All exterior exit discharge lamps had only one lamp in the fixture. The entire perimeter of the building was reviewed from all exit discharge locations and no double lamps within the fixtures to a public way were observed. None of the exterior light fixtures were observed close enough to provide overlapping coverage or be considered a second lamp, except at the main entrance. The Public Way is considered where an emergency response vehicle (I.E, an ambulance) can pull up to the sidewalk egress pathway. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.2.8 & 7.8.1.4. Also see reference section A7.8.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure for continuous lighting of the egress path. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 12:40 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Yellow Zone-SC, Penthouse #2 Stairwell and Orange Zone-SC, Penthouse #1 Stairwell, that the stairwell light switches, when turned-off, circumvented all emergency illumination and as confirmed provided 'no illumination' along the path of egress at these locations and other stair locations. It was also noticed there was no unique identification at these switches to inform the user these switches tied to the emergency generator by a uniquely colored plate or toggle switch. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.2 and NFPA 70 (1999 ed.) articles 400 & 517.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies, and documentation of the alarm transmission to a monitoring station during a fire drill. This deficiency occurred in 7 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/25/2014 at 11:00 am, record review revealed that facility fire drill reports for the prior 12 months revealed that there was no documentation of the fire drills included the transmission of the fire alarm signal. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

2. On 03/25/2014 at 11:05 am, record review revealed that facility fire drill records for the past 12 months revealed that fire drills were not conducted at varied locations. During the 2nd Shift in the 3rd & 4th Quarters, the location was the same: Yellow Zone at the Pull Station #1. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

3. On 03/25/2014 at 11:10 am, record review revealed that facility fire drill records for the past 12 months revealed that fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. During the 2nd Shift in the 3rd & 4th Quarters, the time was within 30 minutes of each other and should be spaced a minimum of 1 to 2 hours apart. 3rd Quarter @ 5 PM and 4th Quarter @ 5:30 PM. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

4. On 03/25/2014 at 11:15 am, record review revealed that facility fire drill documents that the time was missed in the 2nd Shift of the 2nd Quarter. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, and unobstructed water distribution. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 2:50 pm, observation revealed on the 1st floor in the Orange Zone-SC, Resident Storage Room #1101, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a center island wood storage shelving that was within 12 inches of the ceiling causing water spray blockage. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

2. On 03/24/2014 at 3:49 pm, observation revealed on the 1st floor in the Green Zone-SC, Unit B, Inpatient Sleeping Rooms #1192 & #1194, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a metal cage protector for the smoke detector mounted at the ceiling. The cage was within several inches of the head itself. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation, interview, and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have all required sprinkler system inspections, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 7 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/25/2014 at 9:00 am, record review revealed that the sprinkler system maintenance was not compliant. During a review of the Monthly, Semi-Annual and Annual Sprinkler Inspection Report by Mared Mechanical Contractors, Inc., dated through 2013, it was discovered that the fast response sprinkler heads were not test sampled for operation when in use for more than 20 years. The building sprinkler system was installed in 1993 and this process should have been started in 2013 per the Annual Test Report. This testing was incorrectly marked Not Applicable per NFPA 25 (1999 ed.) section 2-3.1.1 Exception No. 2. The facility added a anti-freeze system in 2005. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1.

2. On 03/24/2014 at 11:15 am, observation revealed on the 1st floor in the Red Zone-SC, open cubicle area of Community Support Program (CSP), that the escutcheon ring on the sprinkler was missing. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

3. On 03/24/2014 at 12:53 pm, observation revealed on the 1st floor in the Yellow Zone-SC, Classroom #1064 & Closet #1067, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch diameter in the tile near a sprinkler head and a continuous 1/8 inch opening hole around the escutcheon ring. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

4. On 03/24/2014 at 1:13 pm, observation revealed on the 1st floor in the Yellow Zone-SC, Meeting Room #1074 & Break Room, that there was one or more unsealed holes near the ceiling. The hole(s) included two holes in ceiling near two different escutcheon rings at the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

5. On 03/24/2014 at 2:45 pm, observation revealed on the 1st floor in the Orange Zone-SC, Data/Phone Room #1105, that there was one or more unsealed holes near the ceiling. The hole(s) included a 12' x 24" hole. Ceiling tile was removed by people pulling data wires. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

6. On 03/24/2014 at 2:55 pm, observation revealed on the 1st floor in the Orange Zone-SC, General Storage Room #1099, that there was one or more unsealed holes near the ceiling. The hole(s) included two 4 inch diameter holes plus one 1 inch diameter hole and two holes in the existing ceiling tiles. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

7. On 03/24/2014 at 3:03 pm, observation revealed on the 1st floor in the Orange Zone-SC, Laundry Room #1117, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

8. On 03/24/2014 at 3:30 pm, observation revealed on the 1st floor in the Green Zone-SC, Units A & B Nurses Station, Pharmacy, Charting Room and Staff Support Rooms, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, fixed wiring rather than extension cords, and electrical panels with complete directories. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 2:24 pm, observation revealed on the 1st floor in the Orange Zone-SC, Loading Dock #1092, that access to electrical panel was less than 3'-0" clearance. There were multiple electrical panels on three walls within the Loading Dock area. The electrical panels were blocked by ladders, personal bags, refuse cart, work cart, wood storage shelving leaning up against the wall and other housekeeping supplies. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

2. On 03/24/2014 at 2:58 pm, observation revealed on the 1st floor in the Orange Zone-SC, Housekeeping Room #1112, that access to electrical panel was less than 3'-0" clearance. The electrical panel within the room was blocked by a housekeeping cart. The room is so small the only place to store the cart is in front of the electrical panel. There is not enough room within the space for everything being placed within this room. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

3. On 03/25/2014 at 10:15 am, observation revealed on the 1st floor in the Orange Zone-SC, Electrical Room, that access to electrical panel was less than 3'-0" clearance. Numerous electrical panels were blocked by equipment, ladders, wood shelving unit leaning against the wall and other equipment not related to electrical system. The emergency generator transfer switchgear is located within this room. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

4. On 03/24/2014 at 11:55 am, observation revealed on the 1st floor in the Red Zone-SC, open cubicle area of Community Support Program (CSP), that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. These strip plugs were used to provide power to several coffee makers in several cubicles. This observed situation was not compliant with NFPA 70 (1999 ed.), articles 400-8(1) and 517-18.

5. On 03/25/2014 at 9:58 am, observation revealed on the 1st floor in the Orange Zone-SC, Electrical Room, that electrical panel breakers were not labeled to identify the loads they fed. Panel #E, breakers #2, 4 & 6 where in an 'ON' position and were not identified. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing, and sealed floor penetrations. This deficiency occurred in 3 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 12:47 pm, observation revealed on the 1st floor in the Smoke Barriers between Yellow Zone and Red Zone, that fire proofing was missing from the structural steel at the smoke barrier up tight to the penthouse floor above. Due to location of the steel beam and height of beam, staff B and the surveyor could not verify the intent of this steel beam. However, at minimum the beam must be protected to at least 1-hour where it penetrates the smoke barrier. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

2. On 03/24/2014 at 2:35 pm, observation revealed on the Basement floor in the Orange Zone-SC, Boiler Room B106, that there was a penetration through the floor that was not fire stopped according to an approved method. The deficiency included a 2 inch diameter hole through the floor assembly. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with ducts in rated walls with fire dampers, and sealed wall penetrations. This deficiency occurred in 4 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 12:40 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Yellow Zone-SC, Penthouse #2, that one or more air ducts penetrated the horizontal floor enclosure and could not be confirmed to have a properly installed fire damper. The duct located in the corner of the room did not have a fire damper and it could not be confirmed if a fire damper was installed to separate this 2-hour floor assembly from the lower levels. All other penetrations through the floor were protected to a 2-hour fire rating, including the penthouse stairwell enclosure. This observed situation was not compliant with NFPA 90A (1999 ed.), sections 3-3.2 or 3-3.3 or 3-3.4.

2. On 03/24/2014 at 3:14 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Orange Zone-SC, Penthouse #1, that one or more air ducts penetrated the horizontal floor enclosure and could not be confirmed to have a properly installed fire damper. The duct located in the corner of the room did not have a fire damper and it could not be confirmed if a fire damper was installed to separate this 2-hour floor assembly from the levels below. All other penetrations through the floor were protected to a 2-hour fire rating, including the penthouse stairwell enclosure. This observed situation was not compliant with NFPA 90A (1999 ed.), section 3-3.2 or 3-3.3 or 3-3.4.

3. On 03/24/2014 at 2:26 pm, observation revealed on the 1st floor in the Orange Zone-SC, Elevator Shaft, from the elevator lobby that penetrations in a vertical shaft were not sealed according to an approved method. The deficiency included a 1 inch hole at a pipe in the shaft. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

4. On 03/24/2014 at 2:40 pm, observation revealed on the Basement floor in the Orange Zone-SC, Elevator Equipment Room, that penetrations in a vertical shaft were not sealed according to an approved method. The deficiency included a 4 inch hole in the wall where the pipe from the elevator equipment penetrated the wall into the elevator shaft. This hole was not there during the last federal survey. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 2:07 pm, observation revealed on the 1st floor in the Orange Zone-SC, Corridor Door at a 2-hour Wall Assembly, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.6 and 8.3.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain hazardous room door assemblies that meet code requirements for doors held-open with the required safe guards. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 2:13 pm, observation revealed on the 1st floor in the Orange Zone-SC, Kitchen Storage Room #1089, that the hazardous room door was prevented from self-closing by a door stop. Hazardous room door had a door closer. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.8.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide enclosures around exit stairs with taped joints on rated walls. This deficiency occurred in 2 of the 7 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 12:30 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Yellow Zone-SC, Stairwell to Penthouse #2, that the enclosing stairwell walls were not constructed to a 2-hour fire resistance rating because not all of the drywall joints were taped and/or screws covered with drywall compound as required for designs for rated walls. Stairwell enclosure was designed to a 2-hour fire rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4 and 8.2.3.2, and 7.1.3.2.1.

2. On 03/24/2014 at 3:07 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Orange Zone-SC, Stairwell to Penthouse #1, that the enclosing stairwell walls were not constructed to a 2-hour fire resistance rating because not all of the drywall joints were taped and/or screws covered with drywall compound as required for designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4 and 8.2.3.2, and 7.1.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps at the exterior means of egress so the path would be illuminated if any single fixture or bulb failed at egress paths with redundant lighting. This deficiency occurred outside and affected all the interior 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 11:00 am, observation revealed on the 1st floor in the Red Zone-SC, Exit Door #16, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. Egress lighting is required from the exit discharge to the Public Way or 50'-0", whichever is shorter. All exterior exit discharge lamps had only one lamp in the fixture. The entire perimeter of the building was reviewed from all exit discharge locations and no double lamps within the fixtures to a public way were observed. None of the exterior light fixtures were observed close enough to provide overlapping coverage or be considered a second lamp, except at the main entrance. The Public Way is considered where an emergency response vehicle (I.E, an ambulance) can pull up to the sidewalk egress pathway. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 19.2.8 & 7.8.1.4. Also see reference section A7.8.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure for continuous lighting of the egress path. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 12:40 pm, observation revealed on the Enclosed HVAC Penthouse floor in the Yellow Zone-SC, Penthouse #2 Stairwell and Orange Zone-SC, Penthouse #1 Stairwell, that the stairwell light switches, when turned-off, circumvented all emergency illumination and as confirmed provided 'no illumination' along the path of egress at these locations and other stair locations. It was also noticed there was no unique identification at these switches to inform the user these switches tied to the emergency generator by a uniquely colored plate or toggle switch. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1.2 and NFPA 70 (1999 ed.) articles 400 & 517.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on record review and interview, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies, and documentation of the alarm transmission to a monitoring station during a fire drill. This deficiency occurred in 7 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/25/2014 at 11:00 am, record review revealed that facility fire drill reports for the prior 12 months revealed that there was no documentation of the fire drills included the transmission of the fire alarm signal. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

2. On 03/25/2014 at 11:05 am, record review revealed that facility fire drill records for the past 12 months revealed that fire drills were not conducted at varied locations. During the 2nd Shift in the 3rd & 4th Quarters, the location was the same: Yellow Zone at the Pull Station #1. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

3. On 03/25/2014 at 11:10 am, record review revealed that facility fire drill records for the past 12 months revealed that fire drills were not conducted at varied times. More than two drills were conducted in the same shift within an hour of each other. During the 2nd Shift in the 3rd & 4th Quarters, the time was within 30 minutes of each other and should be spaced a minimum of 1 to 2 hours apart. 3rd Quarter @ 5 PM and 4th Quarter @ 5:30 PM. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

4. On 03/25/2014 at 11:15 am, record review revealed that facility fire drill documents that the time was missed in the 2nd Shift of the 2nd Quarter. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, and unobstructed water distribution. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 2:50 pm, observation revealed on the 1st floor in the Orange Zone-SC, Resident Storage Room #1101, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a center island wood storage shelving that was within 12 inches of the ceiling causing water spray blockage. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

2. On 03/24/2014 at 3:49 pm, observation revealed on the 1st floor in the Green Zone-SC, Unit B, Inpatient Sleeping Rooms #1192 & #1194, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a metal cage protector for the smoke detector mounted at the ceiling. The cage was within several inches of the head itself. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation, interview, and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have all required sprinkler system inspections, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 7 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/25/2014 at 9:00 am, record review revealed that the sprinkler system maintenance was not compliant. During a review of the Monthly, Semi-Annual and Annual Sprinkler Inspection Report by Mared Mechanical Contractors, Inc., dated through 2013, it was discovered that the fast response sprinkler heads were not test sampled for operation when in use for more than 20 years. The building sprinkler system was installed in 1993 and this process should have been started in 2013 per the Annual Test Report. This testing was incorrectly marked Not Applicable per NFPA 25 (1999 ed.) section 2-3.1.1 Exception No. 2. The facility added a anti-freeze system in 2005. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2. and Table 2-1.

2. On 03/24/2014 at 11:15 am, observation revealed on the 1st floor in the Red Zone-SC, open cubicle area of Community Support Program (CSP), that the escutcheon ring on the sprinkler was missing. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

3. On 03/24/2014 at 12:53 pm, observation revealed on the 1st floor in the Yellow Zone-SC, Classroom #1064 & Closet #1067, that there was one or more unsealed holes near the ceiling. The hole(s) included 1 inch diameter in the tile near a sprinkler head and a continuous 1/8 inch opening hole around the escutcheon ring. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

4. On 03/24/2014 at 1:13 pm, observation revealed on the 1st floor in the Yellow Zone-SC, Meeting Room #1074 & Break Room, that there was one or more unsealed holes near the ceiling. The hole(s) included two holes in ceiling near two different escutcheon rings at the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

5. On 03/24/2014 at 2:45 pm, observation revealed on the 1st floor in the Orange Zone-SC, Data/Phone Room #1105, that there was one or more unsealed holes near the ceiling. The hole(s) included a 12' x 24" hole. Ceiling tile was removed by people pulling data wires. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

6. On 03/24/2014 at 2:55 pm, observation revealed on the 1st floor in the Orange Zone-SC, General Storage Room #1099, that there was one or more unsealed holes near the ceiling. The hole(s) included two 4 inch diameter holes plus one 1 inch diameter hole and two holes in the existing ceiling tiles. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1.

7. On 03/24/2014 at 3:03 pm, observation revealed on the 1st floor in the Orange Zone-SC, Laundry Room #1117, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

8. On 03/24/2014 at 3:30 pm, observation revealed on the 1st floor in the Green Zone-SC, Units A & B Nurses Station, Pharmacy, Charting Room and Staff Support Rooms, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, fixed wiring rather than extension cords, and electrical panels with complete directories. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 03/24/2014 at 2:24 pm, observation revealed on the 1st floor in the Orange Zone-SC, Loading Dock #1092, that access to electrical panel was less than 3'-0" clearance. There were multiple electrical panels on three walls within the Loading Dock area. The electrical panels were blocked by ladders, personal bags, refuse cart, work cart, wood storage shelving leaning up against the wall and other housekeeping supplies. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

2. On 03/24/2014 at 2:58 pm, observation revealed on the 1st floor in the Orange Zone-SC, Housekeeping Room #1112, that access to electrical panel was less than 3'-0" clearance. The electrical panel within the room was blocked by a housekeeping cart. The room is so small the only place to store the cart is in front of the electrical panel. There is not enough room within the space for everything being placed within this room. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

3. On 03/25/2014 at 10:15 am, observation revealed on the 1st floor in the Orange Zone-SC, Electrical Room, that access to electrical panel was less than 3'-0" clearance. Numerous electrical panels were blocked by equipment, ladders, wood shelving unit leaning against the wall and other equipment not related to electrical system. The emergency generator transfer switchgear is located within this room. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

4. On 03/24/2014 at 11:55 am, observation revealed on the 1st floor in the Red Zone-SC, open cubicle area of Community Support Program (CSP), that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. These strip plugs were used to provide power to several coffee makers in several cubicles. This observed situation was not compliant with NFPA 70 (1999 ed.), articles 400-8(1) and 517-18.

5. On 03/25/2014 at 9:58 am, observation revealed on the 1st floor in the Orange Zone-SC, Electrical Room, that electrical panel breakers were not labeled to identify the loads they fed. Panel #E, breakers #2, 4 & 6 where in an 'ON' position and were not identified. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff B (Maintenance Mechanic II).
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