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Based on observation and interview with staff, the facility failed to provide corridors separated from use areas by walls constructed with at least 1/2 hour fire resistance rating per 19.3.6.2.1. Findings:

1) Some exit corridor walls were found (a) to have an open gap between the top of the gypsum board and the bottom of the roof deck; (b) to have unrated penetrations; (c) to have areas where gypsum board is missing above the ceiling.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1. Findings:

1) The soiled utility rooms are not sprinklered and thus require one-hour fire rated construction. Walls in these rooms were found to not be intact above the ceiling, and the doors into these rooms do not have the required closers.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 18.5.2.1 and 9.2. Findings:

1) Exhaust fans in toilet rooms are not operational.

The storage and handling of flammable liquids or gases shall be in accordance with NFPA 30, Flammable and Combustible Liquids Code. 8.4.3.1 (1).

Based on observation and interview with staff, the facility failed to provide flammable liquids stored in accordance with NFPA 30 Flammable and Combustible Liquids Code. Findings:

1) Cans of paint, paint thinner, and lacquer were found stored in the basement mechanical room in violation of NFPA 30, Chapter 9 Storage of Liquids in Containers.

Based on observation and interview with staff, the facility failed to provide pressure alarms in accordance with NFPA 99, 4.3.1.2.2. Findings:

1) There is no oxygen high alarm for +/- 20% operating pressure at the medical gas alarm panel.

Based on observation and interview with staff, the facility failed to inspect the generator weekly and exercise the generator under load for 30 minutes per month. Findings:

1) Documentation of generator inspections and run loads were not found.

Based on observation and interview with staff, the facility failed to provide a Type I EES in accordance with NFPA 99, Section 3.4.2.2.2. Findings:

1) The facility failed to provide a Type I EES comprised of two separate systems: the Emergency System and the Equipment System. The Emergency System shall be divided into the Life Safety Branch and the Critical Branch, and shall supply power to those items and areas identified in 3.4.2.2.2 (b) and (c). The Equipment System shall supply power as identified in 3.4.2.2.3.

2) There is no 90 minute emergency back-up lighting over the transfer switch.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings:

1) Open junction boxes (electrical boxes with no cover plate) were found throughout the facility. Some of these open junction boxes are of inadequate size to house all the wiring connected in the boxes.