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Based upon observation and interview, the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7 and continuously maintained free of all obstructions to full use in case of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect 75 occupants in the event of a fire.

Findings include:

* On 04/18/17 at approximately 1:00 PM observed that the "Alternate Emergency Exit Door" in the Center Stairwell, was difficult to open when tested.

This finding was observed and confirmed by the Maintenance Staff at the time of the inspection.

Based upon observation and interview, the facility failed to ensure that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings are enclosed with construction having a fire-resistance rating of at least 1 hour as required by 19.3.1.1 through 19.3.1.6. This deficient practice could affect 169 occupants in the event of a fire.

Findings Include:
On 04/18/17, at approximately 2:15 PM, observed the following violation:

* Observed that the stairwell door in the 4th floor elevator lobby did not fully close and self-latch when tested.

This finding was observed and confirmed by the Maintenance Staff at the time of the inspection.

Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect 169 occupants in the event of a fire.

Findings include:

On 04/18/17 between the hours of 9:45 AM and 3:45 PM , observed the following violations:

* Observed that the dryer duct in the Paint shop is disconnected.

* Observed that linen storage room 534 is not sprinkler protected.

* Observed multiple unsealed penetrations above door to Telephone room 199.

* Observed multiple unsealed wall penetrations in the B-15A Janitor's closet.

* Observed the door to linen storage B66 blocked open.

* Observed that the fire doors to Warehouse Storage B49B blocked open.

* Observed the dryer duct in laundry room 332 is disconnected.

* Observed the dryer duct in laundry room is crushed and obstructing air flow.

These findings were observed and confirmed by the Maintenance Staff at the time of the inspection.

Based upon observation, records review and interview, the facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program complying with National Fire Protection Association (NFPA) 70. This deficient practice could affect 169 occupants in the event of a fire.

Finding's Include:
On 04/18/17, at approximately 2:15 PM, observed the following:

* Observed that the duct smoke detector at room 618 is in alarm.

* Observed exposed fire alarm wires above the secured door at the first floor front counter (public safety).

* On 4/19/17 at approximately 1:45 PM, review of records indicate that multiple elevator phone jacks are not reporting to the fire alarm control panel (FACP).

* On 4/19/17 at approximately 1:45 PM review of records indicate that the fire alarm batteries in electrical room, by center stairwell, failed testing.

These findings were observed and confirmed by the Maintenance Staff.

Based upon observation and interview, the facility failed to ensure that portable fire extinguishers are selected, installed, inspected and maintained in accordance with NFPA 10 as required by 19.3.5.12. This deficient practice could affect 169 occupants in the event of a fire.

Findings Include:

On 04/19/17, at approximately 10:15 AM, observed that the fire extinguisher in the 5th floor nurse's station was last inspected in 2015.

This finding was observed and confirmed by the Maintenance Staff at the time of the inspection.

Based upon observation and interview, the facility failed to ensure that corridors are separated from use areas by walls of at least 1/2-hour fire resistance rating or meet the requirements of smoke partitions in smoke compartments protected throughout by a supervised, automatic sprinkler system as required by 19.3.6.2 and 19.3.6.2.7. This deficient practice could affect 169 occupants in the event of a fire

Findings:
On 04/19/17, at approximately 11:15 AM, observed the following:

* Observed an unsealed wall penetration behind the junction box, above door to room 526.

* Observed an unsealed wall/conduit penetrations in HVAC (heating, ventilation, and cooling) pipe chase, in room 437.

* Observed an unsealed wall penetrations above door to room 338.

* Observed an unsealed wall/conduit penetrations in HVAC pipe chase, in room 337.

* Observed an unsealed wall penetration above door to room 245. (Corrected while onsite)

* Observed an unsealed wall penetration above door to room 239. (Corrected while onsite)

* Observed an unsealed wall penetration above door to room 220. (Corrected while onsite)

* Observed unsealed penetrations in Mechanical room B40

These finding were observed and confirmed by the Maintenance Staff at the time of the inspection.

Based upon observation and interview, the facility failed to ensure that smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5 as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect 169 occupants in the event of a fire.

Findings Include:

On 04/18/17, at approximately 2:50 PM, observed the following:

* Observed an unsealed wall/conduit penetrations, above the cross-corridor smoke barrier doors, at room 618.

* Observed an unsealed wall/conduit penetrations, above the cross-corridor smoke barrier doors, at room 628.

* Observed the duct pulling away from the wall, above the cross-corridor smoke barrier doors, at room 605.

* Observed an unsealed wall/conduit penetrations, above the cross-corridor smoke barrier doors, at room 419.

* Observed an unsealed wall/conduit penetrations, above the cross-corridor smoke barrier doors, at room 318.

* Observed an unsealed wall/conduit penetrations, above the cross-corridor smoke barrier doors, at room 218.

* Observed an unsealed wall/conduit penetrations, above the cross-corridor smoke barrier doors, at room 165.

* Observed an unsealed wall/conduit penetrations, above the cross-corridor smoke barrier doors, at the loading dock.

These findings were observed and confirmed by the Maintenance Staff at the time of the inspection.

Based upon observation and interview, the facility failed to ensure that doors in smoke barriers are 1 3/4 inch solid bonded wood-core doors or construction that resists fire for 20 minutes, are self-closing or automatic-closing and provide a minimum width of 32 inches as required by 19.3.7.6, 18.3.7.8, and 19.3.7.9. This deficient practice could affect 169 occupants in the event of a fire.

Findings Include:

On 04/19/17, at approximately 12:50 PM, observed the following:

* Observed that the aligner on the cross-corridor smoke barrier door, at room 192, did not function when tested.

* Observed that the aligner on the cross-corridor smoke barrier door, at employee lounge, did not function when tested.

These findings were observed and confirmed by the Maintenance Staff at the time of the inspection.

Based upon observation, the facility failed to ensure that openings in smoke barrier doors were fire-rated glazing or wired glass panels in steel frames as required by 19.3.7.6, 19.3.7.6.2, and 8.5. This deficient practice could affect 169 occupants in the event of a fire.

Findings Include:

On 04/19/17, at approximately 12:50 PM, observed the following violation:

* Observed that the glass in the cross-corridor smoke barrier door, at the training room is not rated.

This finding was observed and confirmed by the Maintenance Staff at the time of the inspection.

Based upon observation and interview, the facility failed to ensure that all patient-care related electrical equipment is tested and maintained as required by 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, and 10.5.8 of NFPA 99. This deficient practice could affect 169 occupants in the event of a fire.

Findings Include:

On 04/18/17, between the hours of 9:45 AM and 3:45 PM, observed the following violations:

* Observed exposed wiring above and to the left of door to "Cell Block 9".

* Observed junction boxes missing protective cover above duct, at Print Room.

* Observed a junction box missing protective cover above the East 2-hour rated doors, separating main building from annex.

* Observed an improperly mounted lighted fixture (hanging by wires) in Janitor's closet B15A.

* Observed a junction box missing protective cover in kitchen, to right of exhaust hood.

* Observed exposed wires above door to powerhouse tunnel.

These findings were observed and confirmed by the Maintenance Staff at the time of the inspection.