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Based on observation, interview, and record review the facility failed to ensure class "A" textile materials on walls do not exceed 4-feet in height.(NFPA 10.2.4.1.3) The findings include:1. Observation and interview with the Maintenance Director, on 3/17/2015 at 11:45 AM confirmed the 1st floor corridor walls and 2-West corridor walls had a carpet-like textile wall covering above 48 inches above the finished floor.
2. Record review with the Maintenance Director, on 3/17/2015 at 2:45 PM confirmed the textile wall covering was a class "A" material. These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on 3/17/2015.

Based on observation and interview, the facility failed to ensure corridor doors closed to a positive latch. (NFPA 101, 19-3.6.3.)
The findings include:Observation and interview with the Maintenance Director, on 3/17/2015 at 2:27 PM confirmed the corridor door to the janitor's closet on the 2nd floor by fire door FD-22 failed to close to a positive latch.This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on 3/17/2015.

Based on observation and interview, the facility failed to ensure stairwell's rated construction is maintained. (NFPA 101, 8.2.5.2)
The findings include:
Observation and interview with the Maintenance Director, on 3/17/2015 at 9:32 AM confirmed an unsealed penetration in the 2-hour rated wall above the lay in ceiling at both the east and west end stairwell fire doors.This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on 3/17/2015.

Based on observation, the facility failed to provide hazardous areas with doors that are self-closing.

The findings include:

1. Observation on 3/17/15 at 2:15 PM revealed the door to the continuous care room is not self-closing, the door closer has been removed. This room is over 50 square feet and is being used for combustible storage.
2. Observation on 3/17/15 at 3:20 PM revealed the chemical storage room 90 minute fire door on back wall that opens up to laundry, the door closer has been removed and is not self-closing anymore.

These findings were verified by the Vice President of the facility and acknowledged by administration during the exit conference on 3/17/15.

Based on observation, testing, and interview, the facility failed to have exits readily accessible at all times.

The findings include:

Observation, testing, and interview with staff and maintenance on 3/17/15 at 3:00 PM revealed the exit by medical records in outpatient therapy is magnetically locked against egress. Staff is not provided with a key for unlocking or disabling the door. The engineering personnel are the only staff that has keys to disable the magnetic lock for this door.
Staff that work in the area or department where this locked exit is located, were aware that fire alarm activation will disable the locking device.

This finding was verified by the Vice President of the facility and acknowledged by administration during the exit conference on 3/17/15.
NFPA 101 19.2.2.2.5

Based on observation, the facility failed to provide sprinkler protection in all areas.

The findings include:

1. Observation on 3/17/15 at 2:05 PM revealed the elevator pit of the hydraulic elevator by laundry is not provided with sprinkler protection.
2. Observation 3/17/15 at 2:35 PM revealed underneath of the bottom landings of 2 of 2 stairwells in outpatient therapy are not provided with sprinkler protection.

These findings were verified by the Vice President of the facility and acknowledged by administration during the exit conference on 3/17/15.
NFPA 13 5-13.6.1* & 5-13.3.2

Based on record review, observation and interview, the facility failed to maintain the sprinkler system.
The findings include:
1. Record review of fire pump annual testing report of February 2015 on March 17, 2015 at 9:10 AM revealed the fire pump only achieved a flow of 1017 GPM, 68% rated capacity. Record review of fire pump annual testing report of February 2014 at 3:15 PM revealed the pump test was at a full 1500 GPM (150%), rated capacity. The facility failed to compare current test results with the previous year's and following up with an explanation or taking corrective action. (NFPA 25, 5-3.5.2 and 5-4.1)
2. Observation and interview with the maintenance director on 3/17/2015 between 10:00 AM and 10:45 AM, confirmed sprinkler piping was used to support non-system components in the 4 East and 4 west corridors and in the dietary corridor. (NFPA 13, 6-1.1.5)
These findings were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on 3/17/2015.

Based on observation and interview the facility failed to maintain fire doors.
The findings include:
Observation and interview with the Maintenance Director, on 3/17/2015 at 2:35 PM confirmed the stairwell fire door in the 2nd floor of building "C", past the sports center, had a gap at the bottom exceeding ¾-inch. (NFPA 80 table 1-11.4)This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on 3/17/2015.

Based on observation and interview, it was determined that the facility failed provide battery-powered emergency lighting.

The findings include:

Observation and interview with the facility director on 3/17/15 at 11:50 AM revealed the automatic transfer switch room located in the basement is not provided with battery powered emergency lighting.

This finding was verified by the Vice President of the facility and acknowledged by administration during the exit conference on 3/17/15.
NFPA 110 5-3.1