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Based on observations, the facility failed to ensure that the building is of a conforming construction type. In buildings with bar joist type roof/ceiling assemblies protected by fire rated suspended ceilings, ceiling construction and ceiling tiles are required to be fire rated protecting the enclosures above the suspended ceiling. Section 19.1.6.2 allows buildings up to 3 stories in height to be of Type I (443), Type I (332), and Type II(222)construction and of Type II(111) construction if the building is protected throughout by automatic sprinklers.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed that the building is classified as 3-story Type II (000) construction due to the lack of the required fire protection of the bar joist floor/ceiling assemblies noted in the following areas:

1. The third floor elevator lobby has non-rated ceiling tiles.
2. The third floor Medication Rooms are equipped with non-rated ceiling tiles.
3. The third floor treatment room has an unsealed void around a sprinkler head.
4. The second floor Solarium's closet ceiling has a 16 "x 16 " section of gypsum wallboard (GWB) removed exposing the unprotected bar joist and floor ceiling assembly.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that all corridor doors close and latch properly into their frames. Section 19.3.6.3.6 requires both upper leaf and lower leaf to be equipped with a latching device and the meeting edges of the upper and lower leaves to be equipped with an astragal, rabbit or bevel.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed:

1. The corridor doors to patient room #'s 201, 202, 204, 309, and the first floor level women's locker room did not latch in their respective door frames.

2. The third floor level North side charting room's corridor Dutch door is not equipped with an astragal, rabbet, or bevel, failing to meet section 19.3.6.3.6.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations, the facility failed to ensure that vision panels are constructed as required. Per the Exception to Section 19.3.6.3.8 there are no restrictions in area and fire resistance of glass and frames in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 2/25/14 and the morning of 2/26/14 revealed there are plain glass vision panels located throughout the smoke compartments in the corridor walls and doors. Sprinkler protection is not provided in the following areas:
- the 2nd floor solarium closet,
- the 3rd floor Dual Unit's new linen closet,
- the 3rd floor South Restricted Items closet,
- the basement GAP/PHP office's alcove, and
- the basement GAP meeting room's closet.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.



12268

Based on observations, the facility failed to assure that smoke barriers are constructed to restrict the movement of smoke. Section 8.3.6.1 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers to be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or to be protected by an approved device that is designed for the specific purpose.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed that:

1. The third floor smoke barrier wall is not smoke tight due to an unsealed void adjacent to the H.V.A.C. duct above the suspended ceiling tiles.

2. The second floor smoke barrier wall is equipped with non-rated plain glass vision panels at the Day Room corridor wall.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors are maintained as required.

THE FINDINGS INCLUDE:

Based on observation while touring the facility on 2/25/14 and 2/26/14 revealed:

1. The third floor cross corridor smoke barrier door, adjacent to the Nurses' station (the Bridge), has a 1/4" x 5' gap between the vision panel frame and the door.

2. The second floor cross corridor smoke barrier door, adjacent to the Nurses' station (the Bridge), is equipped with a 10 " x 10 " non-rated plain glass vision panel. In addition, the door has a ¼ " diameter hole around door cylinder where the lockset was replaced.

3. The second floor Day Room corridor door/ smoke barrier door is not equipped with a door closer.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations, the facility failed to keep stair landings clear in accordance with the requirements. Section 7.2.2.5.3 requires that there be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed that:

1. The Basement level landings of the North and South stairs have enclosed storage areas equipped with doors accessible from within the stair enclosure.

2. The Roof level landing of the South stair is utilized as a storage area for ceiling tiles, carpet (area rugs), and sheet plastic.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

A. Based on observations and confirmed by staff on 2/25 & 26/14, the facility failed to ensure compliance with NFPA 99. Section 3-4.1.1.15 requires a remote annunciator, storage battery powered, to be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

THE FINDINGS INCLUDE:

The facility was not equipped with an audible and visual derangement signal, appropriately labeled, at a continuously monitored location in compliance with NFPA 99.


B. Based on observations and confirmed by staff on 2/25/14, the facility failed to ensure compliance with NFPA 110 "Standard for Emergency and Standby Power Systems". Section 5-7.7 requires emergency generators housed outdoors to be in compliance with chapter 3. Section 3-3.1 states a provision shall be made for units housed outdoors to maintain the energy converter enclosure at not less than 32°F (0°C), or battery heaters shall be provided to maintain battery temperature at a minimum of 50°F (10°C) and shall automatically shut off when the battery temperature reaches 90°F (32°C).

THE FINDINGS INCLUDE:

The facility was not in compliance with NFPA 110, Section 3-3.1 due to the battery not being provided with a battery heater to maintain the battery temperature at a minimum of 50°F (10°C). The battery heater shall automatically shut off when the battery temperature reaches 90°F (32°C).



12268


C. Based on record review and confirmed by staff interview, the facility failed to ensure that battery powered emergency lights are maintained and tested as required. Section 7.9.3 requires a functional test to be conducted at 30-day intervals for not less than 30 seconds and an annual test for not less than 1-1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

THE FINDINGS INCLUDE:

Record review on the morning of 2/25/14 revealed:

1. The battery powered emergency lights on the first floor level back door WHP was documented as failed since 8/20/13. Testing the device on 2/25/14 confirmed the battery pack was not operating and has not operated properly the previous six months.

2. The functional test of the Emergency Battery light Pack outside of room #213, on 2/25/14 revealed a bulb failure.

3. There is no documentation that an annual 1-1/2 hour test was conducted on any of the devices within the previous 12 months.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on record review and staff interview, the facility failed to conduct fire drills as required.

THE FINDINGS INCLUDE:

While conducting document review provided on 2/25/14, the following was noted:

First shift (7:00 A.M. - 3:00 P.M.) fire drills were conducted on:
12/31/13 at 1:50 P.M.,
9/30/13 at 1:30 P.M.,
5/30/13 at 1:45 P.M., and
3/25/13 at 1:25 P.M.

Second shift (3:00 P.M. - 11:00 P.M.) fire drills were conducted on:
12/30/13 at 4:25 P.M.,
9/27/13 at 4:22 P.M.,
6/28/13 at 4:20 P.M., and
3/28/13 at 4:25 P.M.

Third shift (11:00 P.M. - 7:00 A.M.) fire drills were conducted on:
12/31/13 at 6:30 A.M.,
9/30/13 at 6:30 A.M.,
5/15/13 at 6:30 A.M., and
3/28/13 at 6:30 A.M.

1. First, second, and third shift fire drills are conducted without varying times on each of the three shifts. a. Four of four first shift times varied (1:25 P.M. to 1:50 P.M.) 25 minutes,
b. Four of four second shift fire drills times varied (4:20 P.M. - 4:25 P.M.) five minutes, and
c. Four of four third shift fire drills were all conducted at 6:30 A.M. without sounding the alarm nor announcing a Code Phrase. The Maintenance Director said the facility conducts verbal desk drills at each unit individually without an alarm nor an announced code phrase so as not to disturb sleeping patients. None of the third shift fire drills comply with the LSC requirements.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on record review and confirmed by staff, the facility failed to test and maintain records of the fire alarm system in accordance with NFPA 72. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

After reviewing the quarterly inspection/test forms dated 12/4/13, 9/27/13, 6/7/13, 3/27/13, and 12/7/12 it was noted that the facility was not conducting the required testing in accordance with NFPA 72. Documenation provided failed to substantiate the annual testing of the battery charger, an annual 30 minute battery discharge test, and semi-annual load voltage test.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

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 9-2.8 requires wet system pressure gages to be inspected monthly.

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 2/25/14 revealed the following:

1. The facility was unable to provide documentation to substantiate an internal inspection of the wet type sprinkler system's main alarm valve within the past five (5) years.

2. The facility was unable to provide documentation to substantiate that the wet type system pressure gages are inspected monthly.

This was acknowledged by the Facilities Director during the tour and acknowledged by Administration during the exit interview


12268


B. Based on observations, the facility failed to properly maintain the automatic sprinkler system. NFPA #25, Section 2.2.1.1 requires sprinklers to be free of corrosion, foreign material, paint, and physical damage. Any sprinkler shall be replaced that is painted, corroded damaged, or loaded.

NFPA #13. Section 5.1.1 requires sprinklers to be positioned and located so as to provide satisfactory performance with respect to activation time and distribution. Where installed in areas of unobstructed construction, ceilings are required to be smooth. Smooth ceilings are ones which do not impede heat flow or water distribution in a manner that affects the ability of the sprinklers to control or suppress a fire.

NFPA 13, Section 5.1.1(1) requires sprinklers to be installed throughout the premises. Section 5-6.3.4, states sprinklers shall be placed not less than six (6') feet on center.

NFPA 13, section 5-6.4.1.1 requires the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed the following:

1. The sprinkler head recessed cover plates at the second floor level Medication Room and the second floor level north Solarium are painted.

2. The following locations have incorrectly spaced sprinkler heads:
a. The third floor nurses' station has two pendent type sprinkler heads located at five feet on center,
b. the third floor Day Room has two sprinkler heads located at 49 inches on center and a third head 10 feet from a wall.
c. The second floor Medication Room has a recessed cap and a pendent type sprinkler head located at 63 inches on center.

3. The second floor staff office, adjacent to room #201, has one of two sprinkler head(s) deflector above the plane of the ceiling.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observation, the facility failed to ensure that the automatic sprinkler system was installed as required by NFPA 13. Section 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 on 2/25 &26/14 revealed that a pressure gauge is not installed where the municipal water supply pressure can be accurately monitored. Pressure gauges are installed immediately below the control valve of the wet system, however they are not installed on the supply side of the back-flow preventer. A pressure gauge must be installed on the supply side of the back-flow preventer.

This item was acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations, the facility did not ensure that portable electric heaters are prohibited from the building.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 revealed a portable electric heater in the outpatient counseling room, adjacent to the North stair. The Director of Facilities said that the "space heater was broken and / not working. "

This item was acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observation, the facility failed to assure compliance with section 19.3.1.1 which requires any vertical opening to be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall not have less than a 1-hour fire resistance. NFPA 82 , section 3-2.4.3 states that every service opening shall be in a room or compartment that is separated from other parts of the building by a wall, partition, floor, and floor-ceiling assemblies have a fire resistance rating of not less than the required rating of the chute enclosure. NFPA 82, section 3-2.6.1 states that linen chutes shall terminate in a room or discharge directly into a room having a minimum fire resistance rating not less than that specified for the chute.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed that:

The basement Linen Chute Discharge Room is not enclosed as required due to the following:

1. During the afternoon hours of 2/25/14, the 1-1/2 hour rated corridor door did not close and latch when released from the open position. The door's latch mechanism didn't overcome the resistance at the strike plate. During the morning hours of 2/26/14, the corridor door was functioning properly.

2. There is an unsealed void around the electrical conduit corridor wall penetration.

3. The enclosure's corridor door has a ¼ " diameter hole around the door cylinder where the lockset was replaced by a smaller lockset.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

A. Based on observations on 4/26/14, the facility was not in compliance with Section 39.3.1.1. Section 39.3.1.1 requires vertical openings to be protected in accordance with Section 8-2.5. Section 8-2.5.4 requires the fire resistance rating to be in compliance with Section 7.1.3.2.1. Section 7.1.3.2.1 requires exits to be separated by not less than a 1-hour fire resistance rating where the exit connects three stories or less.

THE FINDINGS INCLUDE:

The main stair is not enclosed with one hour rated construction due to the following items.
- The stair is enclosed with an unrated door from the 1st to 2nd floor level.
- The stair is open between the 2nd and 3rd floors.


B. Based on observations on the morning of 2/26/14, the stairs do not meet the requirements of Section 39.2.2.3 and Section 7.2.2. Section 7.2.2.2.1(b) requires the headroom to be a minimum of 6 ft. 8 inches. THE FINDINGS INCLUDE:The main stair's headroom reduces to 71" from the 2nd floor to the 1st floor.


C. Based on observations and confirmed by staff on 2/26/14, the facility failed to ensure that hazardous areas are separated as required.
THE FINDINGS INCLUDE:

The boiler room is open to the basement level. It should be separated with 1 hour rated construction as per sections 39.3.2.1 and 8.4.1.1.


D. Based on interview, observations, and confirmed by staff on the morning of 2/26/14, the facility failed to ensure compliance with section 7.9. Section 7.9.3 states a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

THE FINDINGS INCLUDE:

The facility was not in compliance with Section 7.9.3 for the following reasons:

1. The 30 second monthly and 1 1/2 hours annual testing of the emergency lighting were not conducted.

2. The emergency lighting was not operational on each of the 4 levels of the building.


E. Based on record review and confirmed by staff, the facility failed to test and maintain records of the tests for the back-up batteries to the fire alarm system. LSC Section 4.6.12.1 requires that whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 72, Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

1. While performing the record review on 2/25/14 at approximately 11:00 A.M., it was revealed that the testing of the fire alarm batteries is not documented as required. Documenation was not provided to substantiate that either the semi-annual or annual battery testing was conducted. .

2. The 9/27/13 Cintas report indicated the following items in need of repair:

a. The A/V Bypass button does not sound the panel trouble buzzer when activated.
b. The sprinkler flow switch in the basement of Building 227 will not sound the horns or report to the central station in building 209 which is the area it covers.


F. Based on observation on 2/26/14, the facility was not in compliance with NFPA 25, Section 2.2.1.1 which requires sprinklers to be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

THE FINDINGS INCLUDE:

The facility was not in compliance with NFPA 25, Section 2.2.1.1 as evidenced by several painted sprinkler heads located on the 1st floor of the building.


G. Based on observations and confirmed by staff on 2/26/14, the facility failed to ensure that exit egress routes are properly maintained. Section 7.1.10.1 states means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

The facility did not ensure the means of egress was free of all obstruction due to the snow and ice located on the landing of the 2nd floor level and at the discharge of the fire escape. The most recent snow accumulation had occurred 9 days prior to this observation.


H. The facility was not in compliance with Section 39.3.2.1 which requires hazardous areas to be protected in accordance with Section 8-4. Section 8-4.3.2 does not allow any storage of liquids to be permitted in any location where such storage would jeopardize egress form the structure.

THE FINDINGS INCLUDE:1. A pressure washer, with gas in the fuel tank, was stored in the basement.


I. 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 9-2.8 requires wet system pressure gages to be inspected monthly.

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 2/25/14 revealed the following:

1. The facility was unable to provide documentation to substantiate an internal inspection of the wet type sprinkler system's main alarm valve within the past five (5) years.

2. The facility was unable to provide documentation to substantiate that the wet type system pressure gages are inspected monthly.


J. Based on record review and confirmed by staff, the facility failed to test and maintain records of the fire alarm system in accordance with NFPA 72. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

After reviewing the quarterly inspection/test forms dated 12/4/13, 9/27/13, 6/7/13, 3/27/13, and 12/7/12 it was noted that the facility was not conducting the required testing in accordance with NFPA 72. Documenation provided failed to substantiate the annual testing of the battery charger, an annual 30 minute battery discharge test, and semi-annual load voltage test.



These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on record review and confirmed by staff interview, the facility failed to ensure that the "Emergency Power Supply System"(EPSS) is maintained and tested in accordance with NFPA 110. LSC Section 7.9.3 requires written records of visual inspections and tests to be kept by the owner for inspection by the authority having jurisdiction. NFPA 110, Section 6.4.1 requires EPSSs, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly. Section 6.4.2 requires the generator to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating, or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
LSC Section 7.9.2.3

THE FINDINGS INCLUDE:

Records reviewed on 2/25/14, revealed that the emergency generator and all appurtenant components are not tested monthly. Monthly load tests were documented as performed most recently with a documented 2/25/14 load test, generator hours clock 14.6-15.1 hours. During the afternoon hours of 2/25/14, the generator hours clock was noted as 13.2 hours.

This item was acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations and confirmed by staff interview, the facility failed to ensure that utilities comply with the provisions of Section 9.1. Section 9.1.2 requires electrical wiring and equipment to be installed in accordance with NFPA 70.

Article 370-23 (a) requires surface mounted enclosures mounted on a building or other surface to be rigidly and securely fastened in place. If the surface does not provide rigid and secure support, additional support in accordance with other provisions of this section shall be provided.

Article 300-15 requires electrical wiring to terminate in an approved box.

Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days.

Article 400-8 prohibits flexible cords from being used as a substitute for the fixed wiring of a structure.

THE FINDINGS INCLUDE:

1. There is exposed wiring in the exhaust fan which is located in the bathroom of the basement D.O.C. room. The cover to the fan has been removed.

2. The emergency outlet in the basement GAP Meeting Rooms is not secured in the wall. The outlet is hanging by its wire.

3. The Basement level Phone Room has two ceiling mounted uncovered electrical junction boxes. One box was observed to have exposed wiring.

4. An extension cord is used to supplement power to a water cooler in the basement level GAP/PHP program waiting area.

5. The basement level light toggle switch is broken on the corridor wall outside of the outpatient counseling room, adjacent to North stair.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.
















12268

Based on observations, the facility failed to ensure that the building is of a conforming construction type. In buildings with bar joist type roof/ceiling assemblies protected by fire rated suspended ceilings, ceiling construction and ceiling tiles are required to be fire rated protecting the enclosures above the suspended ceiling. Section 19.1.6.2 allows buildings up to 3 stories in height to be of Type I (443), Type I (332), and Type II(222)construction and of Type II(111) construction if the building is protected throughout by automatic sprinklers.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed that the building is classified as 3-story Type II (000) construction due to the lack of the required fire protection of the bar joist floor/ceiling assemblies noted in the following areas:

1. The third floor elevator lobby has non-rated ceiling tiles.
2. The third floor Medication Rooms are equipped with non-rated ceiling tiles.
3. The third floor treatment room has an unsealed void around a sprinkler head.
4. The second floor Solarium's closet ceiling has a 16 "x 16 " section of gypsum wallboard (GWB) removed exposing the unprotected bar joist and floor ceiling assembly.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that all corridor doors close and latch properly into their frames. Section 19.3.6.3.6 requires both upper leaf and lower leaf to be equipped with a latching device and the meeting edges of the upper and lower leaves to be equipped with an astragal, rabbit or bevel.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed:

1. The corridor doors to patient room #'s 201, 202, 204, 309, and the first floor level women's locker room did not latch in their respective door frames.

2. The third floor level North side charting room's corridor Dutch door is not equipped with an astragal, rabbet, or bevel, failing to meet section 19.3.6.3.6.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations, the facility failed to ensure that vision panels are constructed as required. Per the Exception to Section 19.3.6.3.8 there are no restrictions in area and fire resistance of glass and frames in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 2/25/14 and the morning of 2/26/14 revealed there are plain glass vision panels located throughout the smoke compartments in the corridor walls and doors. Sprinkler protection is not provided in the following areas:
- the 2nd floor solarium closet,
- the 3rd floor Dual Unit's new linen closet,
- the 3rd floor South Restricted Items closet,
- the basement GAP/PHP office's alcove, and
- the basement GAP meeting room's closet.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.



12268

Based on observations, the facility failed to assure that smoke barriers are constructed to restrict the movement of smoke. Section 8.3.6.1 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers to be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or to be protected by an approved device that is designed for the specific purpose.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed that:

1. The third floor smoke barrier wall is not smoke tight due to an unsealed void adjacent to the H.V.A.C. duct above the suspended ceiling tiles.

2. The second floor smoke barrier wall is equipped with non-rated plain glass vision panels at the Day Room corridor wall.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors are maintained as required.

THE FINDINGS INCLUDE:

Based on observation while touring the facility on 2/25/14 and 2/26/14 revealed:

1. The third floor cross corridor smoke barrier door, adjacent to the Nurses' station (the Bridge), has a 1/4" x 5' gap between the vision panel frame and the door.

2. The second floor cross corridor smoke barrier door, adjacent to the Nurses' station (the Bridge), is equipped with a 10 " x 10 " non-rated plain glass vision panel. In addition, the door has a ¼ " diameter hole around door cylinder where the lockset was replaced.

3. The second floor Day Room corridor door/ smoke barrier door is not equipped with a door closer.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations, the facility failed to keep stair landings clear in accordance with the requirements. Section 7.2.2.5.3 requires that there be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed that:

1. The Basement level landings of the North and South stairs have enclosed storage areas equipped with doors accessible from within the stair enclosure.

2. The Roof level landing of the South stair is utilized as a storage area for ceiling tiles, carpet (area rugs), and sheet plastic.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

A. Based on observations and confirmed by staff on 2/25 & 26/14, the facility failed to ensure compliance with NFPA 99. Section 3-4.1.1.15 requires a remote annunciator, storage battery powered, to be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

THE FINDINGS INCLUDE:

The facility was not equipped with an audible and visual derangement signal, appropriately labeled, at a continuously monitored location in compliance with NFPA 99.


B. Based on observations and confirmed by staff on 2/25/14, the facility failed to ensure compliance with NFPA 110 "Standard for Emergency and Standby Power Systems". Section 5-7.7 requires emergency generators housed outdoors to be in compliance with chapter 3. Section 3-3.1 states a provision shall be made for units housed outdoors to maintain the energy converter enclosure at not less than 32°F (0°C), or battery heaters shall be provided to maintain battery temperature at a minimum of 50°F (10°C) and shall automatically shut off when the battery temperature reaches 90°F (32°C).

THE FINDINGS INCLUDE:

The facility was not in compliance with NFPA 110, Section 3-3.1 due to the battery not being provided with a battery heater to maintain the battery temperature at a minimum of 50°F (10°C). The battery heater shall automatically shut off when the battery temperature reaches 90°F (32°C).



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C. Based on record review and confirmed by staff interview, the facility failed to ensure that battery powered emergency lights are maintained and tested as required. Section 7.9.3 requires a functional test to be conducted at 30-day intervals for not less than 30 seconds and an annual test for not less than 1-1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

THE FINDINGS INCLUDE:

Record review on the morning of 2/25/14 revealed:

1. The battery powered emergency lights on the first floor level back door WHP was documented as failed since 8/20/13. Testing the device on 2/25/14 confirmed the battery pack was not operating and has not operated properly the previous six months.

2. The functional test of the Emergency Battery light Pack outside of room #213, on 2/25/14 revealed a bulb failure.

3. There is no documentation that an annual 1-1/2 hour test was conducted on any of the devices within the previous 12 months.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on record review and staff interview, the facility failed to conduct fire drills as required.

THE FINDINGS INCLUDE:

While conducting document review provided on 2/25/14, the following was noted:

First shift (7:00 A.M. - 3:00 P.M.) fire drills were conducted on:
12/31/13 at 1:50 P.M.,
9/30/13 at 1:30 P.M.,
5/30/13 at 1:45 P.M., and
3/25/13 at 1:25 P.M.

Second shift (3:00 P.M. - 11:00 P.M.) fire drills were conducted on:
12/30/13 at 4:25 P.M.,
9/27/13 at 4:22 P.M.,
6/28/13 at 4:20 P.M., and
3/28/13 at 4:25 P.M.

Third shift (11:00 P.M. - 7:00 A.M.) fire drills were conducted on:
12/31/13 at 6:30 A.M.,
9/30/13 at 6:30 A.M.,
5/15/13 at 6:30 A.M., and
3/28/13 at 6:30 A.M.

1. First, second, and third shift fire drills are conducted without varying times on each of the three shifts. a. Four of four first shift times varied (1:25 P.M. to 1:50 P.M.) 25 minutes,
b. Four of four second shift fire drills times varied (4:20 P.M. - 4:25 P.M.) five minutes, and
c. Four of four third shift fire drills were all conducted at 6:30 A.M. without sounding the alarm nor announcing a Code Phrase. The Maintenance Director said the facility conducts verbal desk drills at each unit individually without an alarm nor an announced code phrase so as not to disturb sleeping patients. None of the third shift fire drills comply with the LSC requirements.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on record review and confirmed by staff, the facility failed to test and maintain records of the fire alarm system in accordance with NFPA 72. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

After reviewing the quarterly inspection/test forms dated 12/4/13, 9/27/13, 6/7/13, 3/27/13, and 12/7/12 it was noted that the facility was not conducting the required testing in accordance with NFPA 72. Documenation provided failed to substantiate the annual testing of the battery charger, an annual 30 minute battery discharge test, and semi-annual load voltage test.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

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 9-2.8 requires wet system pressure gages to be inspected monthly.

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 2/25/14 revealed the following:

1. The facility was unable to provide documentation to substantiate an internal inspection of the wet type sprinkler system's main alarm valve within the past five (5) years.

2. The facility was unable to provide documentation to substantiate that the wet type system pressure gages are inspected monthly.

This was acknowledged by the Facilities Director during the tour and acknowledged by Administration during the exit interview


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B. Based on observations, the facility failed to properly maintain the automatic sprinkler system. NFPA #25, Section 2.2.1.1 requires sprinklers to be free of corrosion, foreign material, paint, and physical damage. Any sprinkler shall be replaced that is painted, corroded damaged, or loaded.

NFPA #13. Section 5.1.1 requires sprinklers to be positioned and located so as to provide satisfactory performance with respect to activation time and distribution. Where installed in areas of unobstructed construction, ceilings are required to be smooth. Smooth ceilings are ones which do not impede heat flow or water distribution in a manner that affects the ability of the sprinklers to control or suppress a fire.

NFPA 13, Section 5.1.1(1) requires sprinklers to be installed throughout the premises. Section 5-6.3.4, states sprinklers shall be placed not less than six (6') feet on center.

NFPA 13, section 5-6.4.1.1 requires the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed the following:

1. The sprinkler head recessed cover plates at the second floor level Medication Room and the second floor level north Solarium are painted.

2. The following locations have incorrectly spaced sprinkler heads:
a. The third floor nurses' station has two pendent type sprinkler heads located at five feet on center,
b. the third floor Day Room has two sprinkler heads located at 49 inches on center and a third head 10 feet from a wall.
c. The second floor Medication Room has a recessed cap and a pendent type sprinkler head located at 63 inches on center.

3. The second floor staff office, adjacent to room #201, has one of two sprinkler head(s) deflector above the plane of the ceiling.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observation, the facility failed to ensure that the automatic sprinkler system was installed as required by NFPA 13. Section 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 on 2/25 &26/14 revealed that a pressure gauge is not installed where the municipal water supply pressure can be accurately monitored. Pressure gauges are installed immediately below the control valve of the wet system, however they are not installed on the supply side of the back-flow preventer. A pressure gauge must be installed on the supply side of the back-flow preventer.

This item was acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations, the facility did not ensure that portable electric heaters are prohibited from the building.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 revealed a portable electric heater in the outpatient counseling room, adjacent to the North stair. The Director of Facilities said that the "space heater was broken and / not working. "

This item was acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observation, the facility failed to assure compliance with section 19.3.1.1 which requires any vertical opening to be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall not have less than a 1-hour fire resistance. NFPA 82 , section 3-2.4.3 states that every service opening shall be in a room or compartment that is separated from other parts of the building by a wall, partition, floor, and floor-ceiling assemblies have a fire resistance rating of not less than the required rating of the chute enclosure. NFPA 82, section 3-2.6.1 states that linen chutes shall terminate in a room or discharge directly into a room having a minimum fire resistance rating not less than that specified for the chute.

THE FINDINGS INCLUDE:

Observations while touring the facility on 2/25/14 and 2/26/14 revealed that:

The basement Linen Chute Discharge Room is not enclosed as required due to the following:

1. During the afternoon hours of 2/25/14, the 1-1/2 hour rated corridor door did not close and latch when released from the open position. The door's latch mechanism didn't overcome the resistance at the strike plate. During the morning hours of 2/26/14, the corridor door was functioning properly.

2. There is an unsealed void around the electrical conduit corridor wall penetration.

3. The enclosure's corridor door has a ¼ " diameter hole around the door cylinder where the lockset was replaced by a smaller lockset.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

A. Based on observations on 4/26/14, the facility was not in compliance with Section 39.3.1.1. Section 39.3.1.1 requires vertical openings to be protected in accordance with Section 8-2.5. Section 8-2.5.4 requires the fire resistance rating to be in compliance with Section 7.1.3.2.1. Section 7.1.3.2.1 requires exits to be separated by not less than a 1-hour fire resistance rating where the exit connects three stories or less.

THE FINDINGS INCLUDE:

The main stair is not enclosed with one hour rated construction due to the following items.
- The stair is enclosed with an unrated door from the 1st to 2nd floor level.
- The stair is open between the 2nd and 3rd floors.


B. Based on observations on the morning of 2/26/14, the stairs do not meet the requirements of Section 39.2.2.3 and Section 7.2.2. Section 7.2.2.2.1(b) requires the headroom to be a minimum of 6 ft. 8 inches. THE FINDINGS INCLUDE:The main stair's headroom reduces to 71" from the 2nd floor to the 1st floor.


C. Based on observations and confirmed by staff on 2/26/14, the facility failed to ensure that hazardous areas are separated as required.
THE FINDINGS INCLUDE:

The boiler room is open to the basement level. It should be separated with 1 hour rated construction as per sections 39.3.2.1 and 8.4.1.1.


D. Based on interview, observations, and confirmed by staff on the morning of 2/26/14, the facility failed to ensure compliance with section 7.9. Section 7.9.3 states a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

THE FINDINGS INCLUDE:

The facility was not in compliance with Section 7.9.3 for the following reasons:

1. The 30 second monthly and 1 1/2 hours annual testing of the emergency lighting were not conducted.

2. The emergency lighting was not operational on each of the 4 levels of the building.


E. Based on record review and confirmed by staff, the facility failed to test and maintain records of the tests for the back-up batteries to the fire alarm system. LSC Section 4.6.12.1 requires that whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 72, Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

1. While performing the record review on 2/25/14 at approximately 11:00 A.M., it was revealed that the testing of the fire alarm batteries is not documented as required. Documenation was not provided to substantiate that either the semi-annual or annual battery testing was conducted. .

2. The 9/27/13 Cintas report indicated the following items in need of repair:

a. The A/V Bypass button does not sound the panel trouble buzzer when activated.
b. The sprinkler flow switch in the basement of Building 227 will not sound the horns or report to the central station in building 209 which is the area it covers.


F. Based on observation on 2/26/14, the facility was not in compliance with NFPA 25, Section 2.2.1.1 which requires sprinklers to be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

THE FINDINGS INCLUDE:

The facility was not in compliance with NFPA 25, Section 2.2.1.1 as evidenced by several painted sprinkler heads located on the 1st floor of the building.


G. Based on observations and confirmed by staff on 2/26/14, the facility failed to ensure that exit egress routes are properly maintained. Section 7.1.10.1 states means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

The facility did not ensure the means of egress was free of all obstruction due to the snow and ice located on the landing of the 2nd floor level and at the discharge of the fire escape. The most recent snow accumulation had occurred 9 days prior to this observation.


H. The facility was not in compliance with Section 39.3.2.1 which requires hazardous areas to be protected in accordance with Section 8-4. Section 8-4.3.2 does not allow any storage of liquids to be permitted in any location where such storage would jeopardize egress form the structure.

THE FINDINGS INCLUDE:1. A pressure washer, with gas in the fuel tank, was stored in the basement.


I. 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 9-2.8 requires wet system pressure gages to be inspected monthly.

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 2/25/14 revealed the following:

1. The facility was unable to provide documentation to substantiate an internal inspection of the wet type sprinkler system's main alarm valve within the past five (5) years.

2. The facility was unable to provide documentation to substantiate that the wet type system pressure gages are inspected monthly.


J. Based on record review and confirmed by staff, the facility failed to test and maintain records of the fire alarm system in accordance with NFPA 72. Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

After reviewing the quarterly inspection/test forms dated 12/4/13, 9/27/13, 6/7/13, 3/27/13, and 12/7/12 it was noted that the facility was not conducting the required testing in accordance with NFPA 72. Documenation provided failed to substantiate the annual testing of the battery charger, an annual 30 minute battery discharge test, and semi-annual load voltage test.



These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on record review and confirmed by staff interview, the facility failed to ensure that the "Emergency Power Supply System"(EPSS) is maintained and tested in accordance with NFPA 110. LSC Section 7.9.3 requires written records of visual inspections and tests to be kept by the owner for inspection by the authority having jurisdiction. NFPA 110, Section 6.4.1 requires EPSSs, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly. Section 6.4.2 requires the generator to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating, or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
LSC Section 7.9.2.3

THE FINDINGS INCLUDE:

Records reviewed on 2/25/14, revealed that the emergency generator and all appurtenant components are not tested monthly. Monthly load tests were documented as performed most recently with a documented 2/25/14 load test, generator hours clock 14.6-15.1 hours. During the afternoon hours of 2/25/14, the generator hours clock was noted as 13.2 hours.

This item was acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.

Based on observations and confirmed by staff interview, the facility failed to ensure that utilities comply with the provisions of Section 9.1. Section 9.1.2 requires electrical wiring and equipment to be installed in accordance with NFPA 70.

Article 370-23 (a) requires surface mounted enclosures mounted on a building or other surface to be rigidly and securely fastened in place. If the surface does not provide rigid and secure support, additional support in accordance with other provisions of this section shall be provided.

Article 300-15 requires electrical wiring to terminate in an approved box.

Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days.

Article 400-8 prohibits flexible cords from being used as a substitute for the fixed wiring of a structure.

THE FINDINGS INCLUDE:

1. There is exposed wiring in the exhaust fan which is located in the bathroom of the basement D.O.C. room. The cover to the fan has been removed.

2. The emergency outlet in the basement GAP Meeting Rooms is not secured in the wall. The outlet is hanging by its wire.

3. The Basement level Phone Room has two ceiling mounted uncovered electrical junction boxes. One box was observed to have exposed wiring.

4. An extension cord is used to supplement power to a water cooler in the basement level GAP/PHP program waiting area.

5. The basement level light toggle switch is broken on the corridor wall outside of the outpatient counseling room, adjacent to North stair.

These items were acknowledged by the Facility's Director during the tour and acknowledged by Administration during the exit interview.
















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