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Based on observation, record review, and confirmed by staff, the facility failed to ensure that the building is of a conforming construction type. Section 19-1.6.2 requires buildings 3-stories in height to be of at least Type I (443), Type I (332) or Type II (222). If the building is fully sprinklered it may be of Type II (111) construction.

THE FINDINGS INCLUDE:

Plans were reviewed on 1/15/14 and 1/16/14. The building identified as Building #04 had a plan approval date of 2/28/1973, and was constructed as Type II (222) construction. However, the fire rating of the floor/ceiling assemblies and roof/ceiling assembly has been negated due to the installation of non rated recessed lighting fixtures and air diffusers without fire dampers throughout the building. Therefore, the building is identified as a non-conforming, three-story Type II (000) construction.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.1 states corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Section 19.3.6.2.1 states Corridor walls shall be continuous from the floor to the underside of the floor or roof deck, through any concealed spaces , such as those above suspended ceilings , and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

THE FINDINGS INCLUDE:

Throughout the LSC survey, conducted 1/15/14 through 1/17/14, it was noted:

- The corridor walls have unsealed penetrations above the suspended ceilings. These unsealed penetrations were noted along the first floor level corridor of Building #01 outside of the Kitchen, the Laundry, Medical Records Office.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

Based on observations and confirmed by staff, the facility failed to maintain corridor doors to:
- resist the passage of smoke,
- ensure that there are no impediments to the closing of doors protecting corridor openings ( NOTE: Hold-open devices that release when the door is pushed or pulled - no manual unlatching or releasing action necessary to close) are permitted, such as friction catches or magnetic catches, and
- ensure that corridor doors close completely and latch tightly in their frames.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/15/14 through 1/17/14 revealed the following:

1. The corridor doors to the Cafeteria have a 3/8 inch gap at the door leaf(s) meeting edge,

2. The corridor door to the Patient Accounts Department is held open by a wooden floor wedge,

3. The corridor door to the Kitchen is held open by a wooden floor wedge,

4. The corridor door to Speech Therapy has two 1/2" diameter holes through the door slab where door closing hardware was removed.

5. The corridor door to the Coffee shop (labeled 1-226) rubs on the floor when released from the open position due to a loose hinge.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are properly enclosed.

THE FINDINGS INCLUDE:

Observations while touring the facility on 1/15/14 through 1/17/14 revealed that the Main Electric Room, located on the first floor of Building #03 is not separated from the corridor as required.

1. The non labeled corridor door is not equipped with a door closing device.

2. The room's corridor wall at the door, above the suspended ceiling, has an approximate 12" x 12" unsealed penetration where a section of gypsum wallboard (GWB) is removed allowing electrical metal tubing (EMT) to extend from the electrical room to the corridor.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

Based on observation, the facility failed to assure that stairways (vertical openings) are enclosed or protected in as required. Section 8.2.5.2 states openings through floors, such as stairways shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier. Where enclosure is provided, the construction shall not have less than a 1-hour fire resistance.

THE FINDINGS INCLUDE:

During the LSC survey conducted 1/15/14 through 1/17/14 it was observed that Building #05 second floor level stair doors, identified at stair 5N-2 and stair 5W-2, are not equipped with latching hardware. In addition, the space at the meeting edges of the door leaf(s) is in excess of 3/4".

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

Based on observations, the facility failed to ensure that doors in the path of egress are in accordance with Chapter 7. Section 4.5.3.2 states "In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed." Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.2.1.5.1 requires doors to be arranged to be opened readily from the egress side whenever the building is occupied. Section 7.1.5 requires headroom in a means of egress to be no less than 7'-6" to ceilings and no less than 6'-8" to any projection from the floor. Ceiling height in existing buildings shall not be less than 7"-0".


THE FINDINGS INCLUDE:

On 1/15/14 through 1/17/14 the following was noted:

1. The automatic sprinkler piping installed in Building #01 west stair, between the first and second floor level, measures 6'-4" above the stair.

2. A 12" x 24" fold down tray table is installed on the Building #01 west stair discharge, projecting 12" off of the wall measuring 38" above the stair discharge floor.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

A review of fire drill reports on the morning of 1/15/14, revealed fire drills are not conducted as required. NFPA 101 Life Safety Code 2000 Edition Section 19.7.1.2 states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 P.M.. (2100 hours) and 6:00 A.M.. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

THE FINDINGS INCLUDE:

1. Facility documentation provided and reviewed on 1/15/14 and 1/16/14 revealed that fire drills were conducted at the following times during 2013.

a) First Shift (7:00 A.M. - 3:00 P.M.): 10/30/13 at 10:58 A.M., 7/18/13 at 10:39 A.M., 4/22/13 at 10:35 A.M.and 2/15/13 at 10:32 A.M.
All drills were conducted between the hours of 10:32 A.M. and 10:58 A.M.

b) Second Shift (3:00 P.M. - 11:00 P.M.): 12/17/13 at 4:30 P.M., 11/8/13 at 3:30 P.M., 8/21/13 at 4:01 P.M., 5/29/13 at 3:15 P.M., and 1/28/13 at 3:40 P.M.
All drills were conducted between the hours of 3:15 P.M. and 4:30 P.M.

c) Third Shift (11:00 P.M. - 7:00 A.M.): 9/11/13 at 6:47 A.M., 6/7/13 at 6:51 A.M., and 3/14/13 at 6:45 A.M.
All drills were conducted between the hours of 6:45 A.M. and 6:51 A.M.

The entire shift period is not being utilized to ensure that fire drills are conducted under varied conditions.


2. There is no record of a third shift (11:00 P.M .- 7:00 A.M.) fire drill being conducted for the fourth quarter of 2013. The Director of Safety and Security explained that a drill had been scheduled a for 12/27/13 but due to the unavailability of the fire alarm company to respond and assist with the drill, the drill was postponed and not rescheduled.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. NFPA 101 Life Safety Code 2000 Edition. Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.3.2.1 requires smoke detector sensitivity to be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

Records reviewed and inquiries made on the morning of 1/15/14 failed to provide any information as to the frequency of smoke detector sensitivity testing. Documentation could not be provided to substantiate whether any of the facility's smoke detectors have been tested for sensitivity within the past five (5) years.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. NFPA 72 Section 9.7.2.1 states where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

During the afternoon hours of 1/15/14 while inspecting the facility's automatic sprinkler supply system, it was observed that the Post Indicator Valve (PIV), located outside the facility adjacent to the outpatient entrance, is not electronically supervised. This PIV controls the main water supply to the automatic sprinkler system for the facility.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

Based on record review, the facility failed to ensure that the automatic sprinkler system is maintained and inspected as required. NFPA #25, Sections 1.9 and 1.10 require system components to be inspected and tested in accordance with the intervals specified in the appropriate chapters. Section 9.4.1.2 requires alarm valves and their associated strainers, filters, and restriction orifices to be inspected internally every 5 years. Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years. NFPA #13, Sections 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system.



THE FINDINGS INCLUDE:

An inspection of the facility's automatic sprinkler system and a review of the facility's automatic sprinkler system records on the morning of 1/15/14 revealed the following:

1) A pressure gauge is not installed where the municipal water supply pressure can accurately be monitored. Pressure gauges are installed immediately below the control valves of each (wet & dry) system, however they are not installed on the supply side of the back-flow preventers. A pressure gauge must be installed on the supply side of the back-flow preventers.

2) The facility was unable to provide documentation to substantiate an internal inspection of the main alarm valve within the past five (5) years.

3) The facility was unable to provide documentation to substantiate that pressure gauges have been replaced or tested in the last 5 years.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.

Based on observations, the facility failed to ensure that oxygen is stored in accordance with NFPA 99. Sections 16.3.8, 8.3.1.11.2(h), and 4.3.5.2.1(b)27 require freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart.

THE FINDINGS INCLUDE:

Observations while touring the 3rd floor of Building #04 on the morning of 1/15/14 at approximately 11:00 A.M. revealed that "E" cylinders of oxygen were being stored in bottom of two "baby strollers" and not secured.

This was confirmed by the Vice President of Support Services and reviewed with facility Administration during a summary of survey findings.