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Based on observation and interview, it was determined the facility's construction type failed to meet the requirements of NFPA 101.

Findings Include:Observation and Document Review on July 8, 2011, at 9:00 am revealed the following:

The facility's construction type of a four-story Type III (200) does not meet the requirements of NFPA 101.

Interview with the facility administrator on 7/08/11 at 9:30 am confirmed the construction type does not meet the requirements.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance on one of four floors.

Findings Include:

Observation on 6/30/11 at 9:27am revealed the following:

The therapy room suite 2116 was being held open with a weight.

Interview with the facility administrator on 6/30/11 at 2:30pm confirmed the propped open door.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in one instance on one of two floors.

Findings Include:

Observation on 6/30/11 at 8:49am revealed the following:

The hazardous area security room and central supplies room 1140 were being propped open.

Interview with the facility administrator on 6/30/11 at 2:30pm confirmed the propped open doors.

Based upon observation and interview, it was determined the facility failed to maintain the exit access to be accessible at all times in accordance with regulation on 1 of 1 floors.

Findings include:

Observation on June 30, 2011, revealed the following:
a. At 12:34 pm the main exit door leading out of the education center was being locked by a deadbolt.

Interview with the facility administrator on 6/30/11 at 2:30pm confirmed the problem with the exit doors.

Based on observation and interview, it was determined the facility failed to maintain sprinkler protection throughout the facility.

Findings Include:

Observation on 6/30/11 revealed the following:

a. At 1:20 pm sprinkler protection was not provided at ceiling level throughout the education center, including room 110 and rooms off the gym.
b. At 1:40 pm the portico at the Education Center entrance/exit lacks sprinkler protection.

Interview with the facility administrator on 6/30/11 at 2:00 pm confirmed the sprinkler head were not installed at ceiling level.

Based on observation and interview it was determined the facility failed to supervise the fire pump control valves per NFPA guidelines throughout the building.

Findings include:

Observation on June 30, 2011, @ 14:00 pm revealed that per the sprinkler alarm quarterly inspections that the fire pump control valve is locked but lacks a supervised tamper switch per NFPA requirements.

Interview with the facility administrator on 6/30/11 at 2:30pm confirmed fire pump lacks a supervised tamper switch.

Based upon observation and interview, it was determined that heating, ventilation, and air conditioning is not installed or maintained in accordance with regulations on 1 of 4 floors.

Findings include:

Observation on 6/30/11 @ 10:00 am revealed that the exhaust ductwork behind the clothes dryer in room # 2509 was disconnected and lint was collecting behind the dryer.

Interview with the facility administrator on 6/30/11 at 2:30pm confirmed the ductwork was off behind the dryer.

Based on observation and interview, it was determined the facility failed to maintain gas cylinder requirements in one instance on one of three floors.

Findings Include:

Observation on 6/30/11 at 12:28pm revealed the following:

The helium cylinders in the med gas storage room were not painted brown.

Interview with the facility administrator on 6/30/11 at 2:30pm confirmed the incorrectly color cylinders.

Based upon documentation review and interview it was determined that the facility failed to comply with regulations for generators per the Division of Safety Inspection message board throughout the facility.

Findings include:

Observation on June 30, 2011 revealed that the facility failed to have certified documentation from the outside testing agency/vendor of the generators ability to perform per the manufacturers specifications and the generator shows no signs of wet stacking, or hitting 30% of the nameplate load.

Interview with the facility administrator on 6/30/11 at 2:30pm confirmed the generator is not being tested by an outside contractor and is not performing at 30% of its nameplate.

Based on observation and interview, it was determined the facility failed to maintain electrical requirements in two instances on one of one floor.

Findings Include:

Observation on 6/30/11 revealed the following:

a) At 12:59am, there was exposed electrical wiring in the first floor near room 115 on the first floor.
b) At 1:10pm, there was temporary wiring in the education center in the room off of the gym.

Interview with the facility administrator on 6/30/11 at 2:30pm confirmed the exposed wiring.