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Based on observations and confirmed by staff, the facility failed to ensure that corridor doors are maintained as required. CMS S&C 07-18 dated April 20, 2007 states "In a smoke compartment that is fully sprinklered, a gap between the face of a corridor door and the door stop should not exceed 1/2-inch, provided that the door latch mechanism is functioning".
Section 19.3.6.3.6 states Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 5/4/15 it was observed that numerous doors are not maintained as required. The following items but not limited to were observed regarding corridor doors:

1) The doors to patient rooms 316; 318; 320; 321; 323; 324; 325; 326; 328; 329 and 348 were observed to be obstructed from closing. Each of these locations has a trash receptacle placed on the interior wall on the latching edge side of the door. The receptacles protrude approximately 4" into the door opening preventing the doors from closing and latching as required.
Note: The receptacles were relocated when brought to the attention of the nursing staff.

2) The double doors to the cafeteria do not limit the transfer of smoke. The doors were originally installed using double action hinges allowing the doors to swing in both directions. This type of installation does not utilize door stops for the door to rest against. As a result, there are 1/4" gaps between the doors and the frame as well as between the door leaves. The doors are not able to resist the passage of smoke due to these gaps.

3) The door to room 512 has an approximate 7/8" gap at the top of the door. The door appears to be out of plumb and/or warped, causing the excessive gap. As a result, the door is not able to resist the passage of smoke as required.

4) The medication room door on the 2nd floor level is equipped with a Dutch style door. The top door leaf is equipped with a manually operated barrel latch to engage the leaves together. Each door will not self latch as required when pulled/pushed into the door frame.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

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

THE FINDINGS INCLUDE:

During the afternoon hours of 5/5/15 at approximately 1:15 P.M., it was observed that the overall travel distance between conforming smoke barriers on the 5th floor level exceeds 200'. After observing all of the possible smoke barrier walls for structural integrity, only one wall was found to be compliant, the wall closest to the "A-wing". The travel distance from the corner room of the "B-wing" to the conforming smoke barrier wall is approximately 235'. This exceeds the allowable distance by 35'.
Note: There is another possible smoke barrier wall located by room 521. However, there is a bathroom connecting rooms 521 and 522 where the wall is located. The bathroom door of room 521 is not equipped with a self closing device, therefore the wall is non-compliant.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors are constructed properly. NFPA section 19.3.7.5 states openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than 20 minutes.

THE FINDINGS INCLUDE:

During the afternoon hours of 5/5/15 at approximately 1:15 P.M., it was observed that the single leaf smoke barrier door on the 2nd floor Behavioral Unit located near the common room is equipped with a non-rated plain glass vision panel measuring approximately 36" x 36".

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

While touring the facility on 5/4/15 and 5/5/15, numerous deficiencies were observed regarding Hazardous Areas, these include but are not limited to the following locations:

1) During the morning hours of 5/4/15 at approximately 11:55 A.M., it was observed that the 3rd floor electrical room adjacent to the oxygen storage room is not smoke tight. An approximate 3" unsealed penetration/hole was observed in the room wall.

2) During the afternoon hours of 5/4/15 at approximately 2:35 P.M., it was observed that the door to the pharmacy storage room is not equipped with a self closing device as required.

3) During the morning hours of 5/5/15 at approximately 10:00 A.M., it was observed that the Main Kitchen is not separated as required. The Kitchen has a total of four (4) doors which open to the Garden Room. None of these doors are equipped with self closing devices as required.

4) During the morning hours of 5/5/15 at approximately 10:00 A.M., it was observed that the two sets of storage room doors in the basement of the "C-wing" are not equipped with self closing devices. In addition, the doors have no means of self latching as they are equipped with a dead-bolt style locking device.

5) During the morning hours of 5/5/15 at approximately 9:30 A.M., it was observed that the door to the 1st floor soiled utility room does not self close as required. The door is currently equipped with spring loaded hinges which do not over come the resistance of the door. As a result, the door will not self close and latch as required.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that stairwell doors are maintained as required. NFPA 80 section 2-1.4.1 states self-closing doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened. The closing mechanism shall not have a hold-open feature.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 5/4/15, it was observed that all stairwell doors do not close and latch as required. When tested for proper operation, the following doors were noted as not functioning as required:

1) The 4th floor door of the "A-wing" stairwell does not latch when opened and released.

2) The ground floor door of the "B-wing" stairwell does not latch when opened and released.

3) The 3rd floor double doors of the "A-wing" stairwell do not latch when opened and released.

Note: These items were corrected during the course of the survey.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure compliance with the following exit access regulations included in Chapter 19 and Chapter 7 of the 2000 Edition of NFPA 101 "Life Safety Code"

Finding #1:
The facility failed to ensure that latches and fastening devices on doors in the path of egress are in accordance with Chapter 7 Section 4.5.3.2 which states the following. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building. Chapter 7 Section 7.2.1.5.1 requires doors to be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. Doors shall be operable with not more than one releasing operation.

Finding Includes:
Observations while touring the facility on the morning of 5/05/15, at approximately 10:30 A.M., revealed that the two sliding doors which provide exit access from the front lobby vestibule are equipped with thumbturn deadbolts, the operation of which would not be obvious under poor lighting conditions, and when locked prevent the emergency swing out feature of the doors from functioning properly.

Finding #2:
The facility failed to ensure compliancy with Chapter 7 Section 7.1.10.1 which 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. In areas where there are climatic conditions such as rain or snow which could render a yard or unpaved area unusable, permanent sidewalk must be provided.

Findings Include:
Observations while touring the facility on 5/05/15, between the hours of 10:00 A.M. and 2:45 P.M., revealed the following.

1. The top hinge of the stairway E exit discharge door is distorted and causes the door to bind against its frame resulting in an impediment to full and instant use during emergency conditions.

2. The stairway "B" exit discharge door opens to an approximate five foot by five foot (5' x 5') concrete pad with the path of egress traversing approximately fifteen feet (15') of grass lawn and mulch bed before reaching a permanent walkway. Due to the prevalence of climatic conditions such as rain, snow or ice which could render a yard or unpaved area unusable, permanent sidewalk must be provided.

3. The stairway "D" exit discharge door opens to an approximate five foot by five foot (5' x 5') concrete pad with the path of egress traversing approximately fifteen feet (15') of upward sloping grass lawn before reaching a permanent walkway. Due to the prevalence of climatic conditions such as rain, snow or ice which could render a yard or unpaved area unusable, permanent sidewalk must be provided.

Finding #3:
The facility failed to ensure compliancy with Chapter 7 Section 7.2.1.6.1 which allows the installation of approved, listed, delayed-egress locks to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided criteria which includes the following is met. On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Findings Include:
Observations while touring the facility on 5/05/15, between the hours of 10:00 A.M. and 2:45 P.M., revealed the following.

1. The stairway "A" exit discharge door is equipped with an approved delayed -egress locking device but lacks the notification signage required by Chapter 7 Section 7.2.1.6.1.

2. The cross corridor doors located in the "C-Wing" basement exit corridor are equipped with approved delayed -egress locking devices but lack the notification signage required by Chapter 7 Section 7.2.1.6.1.

As a result of the findings the facility is found to be non-compliant with the above listed regulations of Chapter 7 of the 2000 Edition of NFPA 101 "Life Safety Code".

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

Observations while touring the facility on 5/4/15 revealed that the following

1) The stairwells for "A-wing" and "B-wing" are equipped with numerous light switches accessible to all who traverse the stairwells. When these switches were tested for operation, the stairwell lighting was able to be shutoff putting the stairwell into darkness.

2) The "C-wing " basement corridor has numerous fluorescent light fixtures which are currently non-functional. The corridor which is approximately 120' in length has only two functioning light fixtures. The corridor is extremely dark making the egress route difficult to navigate around any of the obstacles present.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that smoke detectors are installed as required. NFPA 72 section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 5/4/15, it was observed that numerous smoke detectors are located closer than three feet (3') from an air diffuser. These areas include but are not limited to the following rooms/locations: 502; 504; 509; 519; and the corridor by the "B-wing" nursing station.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

1) Based on observations and confirmed by staff, the facility failed to ensure that stairwells are properly sprinklered. NFPA #13 section 5-13.3.1 states sprinklers shall be installed beneath all stairways of combustible construction. Section 5-13.3.2 states in noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.

Findings Include:

During the morning and afternoon hours of 5/4/15, it was observed that not all stairwells are protected by the automatic sprinkler system as required. The following stairwells were observed to be deficient in some manner:

a) The "B-wing" stairwell is not sprinklered at the top of the shaft.
b) The "A-wing" stairwell is not sprinklered at the top of the shaft.
c) The "Center" stairwell is not sprinklered at the top of the shaft.
d) The stairwell connecting the basement and the "Isolation Hospital" building is not sprinklered at the top of the shaft.

2) Based on observations and confirmed by staff, the facility failed to ensure that sprinkler protection is provided as required. Section 19.3.5.1 states where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. This facility is required to be fully sprinklered to meet the numerous exceptions which are utilized by installation of the automatic sprinkler system.

Findings Include:

During the morning hours of 5/5/15 at approximately 11:45 A.M., it was observed that a sprinkler head has been removed and plugged in the hot water storage room of the basement. This missing sprinkler head is located above one of the storage tanks.


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3) Based on observations and confirmed by staff, the facility failed to ensure that sprinkler protection is provided as required. NFPA #13 Section 1-6.1 states a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas. Exception: This requirement shall not apply where specific sections of this standard permit the omission of sprinklers.
NFPA #13 Section 5.13.11 states sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible. Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure which includes protection for penetrations. The opening of the enclosure must be protected by a self-closing, 1.5 hour fire rated door as required in NFPA #101 Section 8.2.3.2.3.1 and NFPA #80 Section 8.2.3.2.1
(d) No combustible storage is permitted to be stored in the room.

Findings Include:

At approximately 2:30 P.M. on the afternoon of 05/04/15, while conducting an inspectional tour of the facility, observations revealed the following deficiency. The #2B electrical closet located on the facility's second floor is not protected by automatic sprinkler coverage and therefore must meet all of the exception requirements included in NFPA #13 Section 5.13.11. Although the closet is dedicated to only dry type electrical equipment and does not contain combustible storage, the 2-hour fire-rating is compromised due to the lack of a non-rated opening protective. At time of observation the pair of doors servicing the electrical closet were lacking any type of fire-rating label. As required by NFPA #101 Section 8.2.3.2.3.1 and NFPA #80 Section 8.2.3.2.1(b) the opening of the enclosure must be protected by a self-closing, 1.5 hour fire rated door.
As a result of the finding the facility is found to be non-compliant with NFPA #13 Section 5.13.11.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

1) Based on observations, the facility failed to ensure that an accurate municipal water supply pressure could be monitored. NFPA #13, Sections 4.7.7 requires a listed pressure gauge to be installed immediately below the control valve of each system. NFPA #25, Section 2.2.4.1 requires gauges on wet pipe sprinkler systems to be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 2.2.4.2 requires gauges on dry pipe sprinkler systems to be inspected weekly to ensure that normal air and water pressures are being maintained.

THE FINDINGS INCLUDE:

Observations while touring the facility on the afternoon of 5/4/15 revealed that pressure gauges are not installed in all required locations to ensure the municipal water supply pressure can accurately be monitored. There is a total of 3 automatic sprinkler systems located in the facility. The sprinkler system located in the Boiler Room has a pressure gauge installed immediately below the control valve, however one is not installed on the supply side (city supply) of the back-flow preventer. Back-flow preventer's allow water to pass through them in one direction locking the water pressure on the system (house) side of the device. This prevents the water pressure on the system side from going down when the pressure on the supply side goes down, such as during peak use periods during the day. A pressure gauge must be installed on the supply side of the back-flow preventer.


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2) Based on observations the facility failed to properly maintain the automatic sprinkler system. NFPA #25 1998 Edition Section 2-3.1.1 states where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. Test procedures shall be repeated at 10-year intervals.
Section 2-3.1.2 states a representative sample of sprinklers shall consist of a minimum of not less than 4 sprinklers or 1 percent of the number of sprinklers per individual sprinkler sample, whichever is greater.
Section 2-3.1.3 states where one sprinkler within a representative sample fails to meet the test requirement, all sprinklers represented by that sample shall be replaced. (See 2-4.1.1.)
Section 2-4.1.1 states replacement sprinklers shall have the proper characteristics for the application intended. These include the following:
(a) Style
(b) Orifice size and K-factor
(c) Temperature rating
(d) Coating, if any
(e) Deflector type (e.g., upright, pendant, sidewall)
(f) Design requirements

Findings Include:
Observations made while conducting the facility tour on the afternoon of 05/05/15, between the approximate hours of 1:00 P.M. and 3:00 P.M., revealed the following. Several compartmented spaces located within the confines of the facility's A & B basement wings are protected by automatic sprinkler heads which are date stamped 1962 and therefore in excess of fifty (50) years old. Included in but not limited to the observed locations are the following: vacuum pump room; maintenance shop; central supply area. In addition to the observations, a review of sprinkler system documentation made available at time of survey indicate that sprinkler head testing in accordance with NFPA #25 1998 Edition Section 2-3.1.1 has not been conducted.

As a result of the finding the facility is found to be non-compliant with NFPA #25 1998 Edition Section 2-3.1. The fifty year old heads must either be replaced or be tested in accordance with NFPA #25 regulations. If replaced documentation shall be provided to verify the characteristics included in NFPA #25 Section 2-4.1.1

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure compliance with NFPA 90A. Section 3.3.1.1 requires approved fire dampers to be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 3.3.1.2 requires approved fire dampers to be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.

Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within.

Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer's installation instructions.

THE FINDINGS INCLUDE:

During the morning hours of 5/4/15 at approximately 11:45 A.M., it was observed that a portable air conditioning (AC) unit is located in the 3rd floor storage room of the "B-wing". The AC unit's exhaust air is currently venting into a vertical shaft which is adjacent to the storage room. The shaft wall had an opening created to accommodate the approximate 5" round venting duct. The shaft which is 6-stories in height is constructed with a 2-hour fire rating requiring fire dampers at all shaft penetrations. The AC duct work is not equipped with a fire damper.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations during the building tour and confirmed by staff, the facility failed to ensure compliance with the restrictions of portable space heating devices. Section 9.7.8 states portable space-heating devices shall be prohibited in all health care occupancies.

THE FINDING INCLUDE:

During the morning hours of 5/4/15 at approximately 11:10 A.M., a portable electric space heater was observed in room 527.

Note: The device was not in use when observed and removed immediately by staff.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the hospital failed to ensure that mobile trash carts are stored properly within enclosed rooms.

THE FINDINGS INCLUDE:

During the afternoon hours of 5/5/15 at approximately 1:20 P.M., it was observed that the 2nd floor "B-wing" level of the facility has a total of three (3) trash containers stored in the corridor. Each of the three trash containers were noted as having a 45-gallon capacity, exceeding the allowable 32-gallon amount. The trash containers are located in the corridor near the Behavioral Unit Dining room.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that liquid oxygen is properly stored/transfilled in accordance with NFPA 99.

THE FINDINGS INCLUDE:

During the morning hours of 5/4/15 at approximately 11:00 A.M., it was observed that the liquid oxygen storage/transfill room located on the 5th floor is not separated as required. When the walls were viewed for structural integrity above the ceiling tiles, numerous unsealed penetrations were observed in the surrounding walls.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that extension cords are used in accordance with NFPA 70. 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 use as a substitute for the fixed wiring of a structure. LSC 19.5.1

THE FINDINGS INCLUDE:

During the morning hours of 5/4/15 at approximately 11:45 A.M., two (2) extension cords were observed in the 4th floor classroom. The cords are substituting permanent wiring to supply electrical power to all of the computer work stations. In addition, at approximately 3:15 P.M., an extension cord was observed in the 2nd floor nurse's charting room.

This was acknowledged by the Administrator, Director of Engineering, and administrative staff during the exit interview process.