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Based on observations and confirmed by staff, the facility failed to ensure corridor walls are constructed as required. Exception No. 6 to 19.3.6.1 states spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

THE FINDINGS INCLUDE:

1. While surveying at approximately 12:00 P.M. on 11/19/14, it was noted that a four inch flexible plastic exhaust duct penetrated the corridor wall, above the suspended ceiling, from the bathroom of room 142 to the corridor. The duct terminated at the fire barrier doors which lead from the Besse to the Glass Building. This negates the required 1/2 hour fire resistance rating of the corridor wall.

2. While touring the facility on 11/18/14 it was observed that the chapel located on the first floor is not provided with corridor walls as required by Section 19.3.6.1 nor does the chapel meet Exception No. 6 to 19.3.6.1 which requires the open space to be protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.

The findings were confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations, the facility failed to ensure that doors protecting corridor openings are in compliance with section 19.3.6.3.

THE FINDINGS INCLUDE:

1) While touring the facility on 11/18/14, it was observed that the basement level patient lounge/activity room (labeled G27) corridor doors have a 1/4" gap at the meeting edge of the doors.


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2) While performing the building tour on both 11/18/14 and 11/19/14, it was observed that the majority of all the patient room doors are not maintained as required. The dual action doors were originally designed with recessed door gaskets on the latching side. This felt strip gasket is attached to an aluminum backing which is recessed into the door edge. The gaskets which are missing from the majority of all the patient room doors are either missing in their entirety or partially missing in each of the units surveyed. In addition, the latching mechanisms are also broken on the majority of the doors in each of the units surveyed. The latching mechanisms are mostly stuck in the retracted position and can no longer achieve positive latching as required. As a result of these issues, the doors are not capable of resisting the passage of smoke.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier walls are properly maintained.

THE FINDINGS INCLUDE:

While performing the building tour on 11/19/14 at approximately 11:00 A.M., it was observed that the 3rd floor smoke barrier is not properly maintained. The smoke wall above the ceiling tiles located within the laundry room has a void around a duct penetration. There is a smoke damper installed on the duct, the damper is recessed into the wall with an approximate 4" x 6" opening around the damper. The wall in this location is not smoke tight as there are gaps through the entire depth of the wall around the damper/duct.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

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

THE FINDINGS INCLUDE:

1. While performing the building tour on 11/18/14 and 11/19/14, it was observed that the trash room doors on the both the 4th & 3rd floor levels are not equipped with self closing devices. These rooms are considered hazardous areas and are required to be separated from the corridors with self closing/latching doors.

2. The non-sprinklered emergency electrical room, which also houses the emergency generator, has unsealed corridor wall penetrations around electrical conduit and piping.

3. The Mechanical Room (labeled G4) has unsealed corridor wall penetrations around electrical, gas, chilled water and sprinkler piping.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations, the facility failed to ensure that hazardous areas are enclosed as required. NFPA 101 Life Safety Code 2000 Edition Chapter 19 Section 19.3.2.1 Hazardous Areas states any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction

THE FINDINGS INCLUDE:

Observations during a tour of the facility in the afternoon of 11/18/14 hours revealed that hazardous areas are not provided with smoke resistant construction as evidenced by the following:

1. The single corridor door to the kitchen was not smoke tight due to various voids in the door around the door knob where hardware had been previously removed.

2. The corridor door to the basement mechanical room was not smoke tight due to a louver, which was equipped with a fire damper, in the door. The corridor door to the mechanical room is required to resist the passage of smoke.

3. The basement Store Room was not smoke tight due to a void around the 4 inch waste line which penetrates the wall to the delivery access area.

4. One of three corridor doors to the basement Store Room was not self closing due to the door being equipped with a self chalking closing device which allows the door to remain in the open position.

5. One of the three corridor doors to the basement Store Room was equipped with a kick stop which also allows the door to remain in the open position.

The finding was confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations, the facility failed to ensure that exit stairways are enclosed as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 11/18/14 and 11/19/14 revealed that:

Each of the "A", "B" "C" , and "D"stairs accessible from the nursing units on the basement level and first floor level have unsealed penetrations or section of block removed from the stair enclosure. This is visible on the corridor side of the stair above the in-lay ceiling tiles (as the ceiling in the stair is monolithic).
Most notably at the following locations:
-"C" stair basement level where a 28" x 16" section of block is missing.
- "A" stair basement level where two unsealed pipe penetrations are noted.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.7.1 requires exits to terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 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.

THE FINDINGS INCLUDE:

While touring the facility on 11/18/14 through 11/20/14 it was observed that the exit discharge from Stair A does not terminate at the public way. It terminates onto a concrete landing and a grass walking surface.

The finding was reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure egress doors are maintained as required. Section 19.2.2.2.4 states doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side. Section 7.2.1.5.1 states doors shall 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.

THE FINDINGS INCLUDE:

While performing the 3-East tour on 11/19/14 at approximately 11:30 A.M., it was observed that each patient room has been converted to office spaces. The original doors and locking mechanisms are still currently in use in these office locations. The doors are equipped with keyed locks from the corridor side only, with no method of release from the egress side of the door. The locks do not meet any code exceptions as the rooms are no longer used for patient care meeting the clinical needs of the patients. Each door has the capability of being locked allowing no egress from the room side as required.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. Section 7.2.4.3.7 requires doors in horizontal exits to be designed and installed to minimize air leakage

THE FINDINGS INCLUDE:

During the morning hours on 11/19/14 while touring the facility, it was observed that the 2 hour fire resistance rating of the fire barrier walls was not maintained above the suspended ceilings in the following areas:

1. The basement level fire barrier located between the Besse and Glass Buildings, in the location of the fire barrier doors, was not maintained as evidenced by voids around two 4" conduits.

2. The basement level fire barrier located between the Besse and Chambers Buildings, in the location of the fire barrier doors, was not maintained as evidenced by a 4" x 4" and 3" x 4" voids and gaps within the 5" cored holes.

Due to these voids, the fire rating of the fire barrier wall is not maintained.

The finding was confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. Section 7.2.4.3.7 requires doors in horizontal exits to be designed and installed to minimize air leakage

THE FINDINGS INCLUDE:

During the morning hours on 11/19/14 while touring the facility, it was observed that the 2 hour fire resistance rating of the fire barrier walls was not maintained above the suspended ceilings in the following areas:

1. The basement level fire barrier located between the Besse and Glass Buildings, in the location of the fire barrier doors, was not maintained as evidenced by voids around two 4" conduits.

2. The first floor fire barrier wall between the kitchen utility closet and the Chambers Building was not maintained as evidenced by voids around various piping.

Due to these voids, the fire rating of the fire barrier wall is not maintained.

The finding was confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 states artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.

Section 7.8.1.4 states required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

THE FINDINGS INCLUDE:

Observations while touring the facility on 11/20/14 revealed that the artificial lighting in Stair A was not functioning, leaving all levels of the stair without adequate illumination.
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The finding was confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that exit signs are properly maintained.
Section 7.10.1.2 states exits other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
Section 7.10.6.1 states externally illuminated signs required by 7.10.1 and 7.10.2, other than approved existing signs, shall have the word EXIT or other appropriate wording in plainly legible letters not less than 6 in. (15.2 cm) high with the principal strokes of letters not less than 3/4 in. (1.9 cm) wide. The word EXIT shall have letters of a width not less than 2 in. (5 cm), except the letter I, and the minimum spacing between letters shall be not less than 3/8 in. (1 cm). Signs larger than the minimum established in this paragraph shall have letter widths, strokes, and spacing in proportion to their height.

THE FINDINGS INCLUDE:

During the afternoon hours of 11/19/14 at approximately 2:00 P.M., the exit sign above stairwell #1 door on the 3-West unit was observed as missing. It was stated by facility staff that the sign was vandalized and removed by a disruptive patient.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted as required.

THE FINDINGS INCLUDE:

During the afternoon hours of 11/19/14, the facility's documentation regarding fire drills was reviewed for code compliance. During review, it was noted that the fire drills are not performed as required. Although the facility is meeting the minimum requirements for the amounts of drills performed, the drills conducted are not varying the conditions as required. The drills are documented as follows:

1st Shift (7:00 A.M.-3:00 P.M.): 11/13/14 @ 10:00 A.M.; 8/6/14 @ 10:00 A.M.; 5/7/14 @ 10:00 A.M.; and 3/4/14 @ 10:15 A.M.

2nd Shift (3:00 P.M.-11:00P.M.): 10/8/14 @ 4:00 P.M.; 7/2/14 @ 4:20 P.M.; 6/11/14 @ 4:00 P.M.; 4/8/14 @ 4:00 P.M.; 2/20/14 @ 4:00 P.M.;and 10/3/13 @ 4:00 P.M.

3rd Shift (11:00 P.M.-7:00 AM.): 9/9/14 @ 6:00 A.M.; 6/18/14 @ 6:00 A.M.; 3/19/14 @ 6:00 A.M.; and 12/6/13 @ 6:00 A.M.

As a result of the drill times being virtually the same for each of the quarterly drills performed, the conditions of the drills are not varied as required.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted as required.

THE FINDINGS INCLUDE:

During the afternoon hours of 11/19/14, the facility's documentation regarding fire drills was reviewed for code compliance. During review, it was noted that the fire drills are not performed as required. Although the facility is meeting the minimum requirements for the amounts of drills performed, the drills conducted are not varying the conditions as required. The drills are documented as follows:

1st Shift (7:00 A.M.-3:00 P.M.): 11/13/14 @ 10:00 A.M.; 8/6/14 @ 10:00 A.M.; 5/7/14 @ 10:00 A.M.; and 3/4/14 @ 10:15 A.M.

2nd Shift (3:00 P.M.-11:00 P.M.): 10/8/14 @ 4:00 P.M.; 7/2/14 @ 4:20 P.M.; 6/11/14 @ 4:00 P.M.; 4/8/14 @ 4:00 P.M.; 2/20/14 @ 4:00 P.M.;and 10/3/13 @ 4:00 P.M.

3rd Shift (11:00 P.M.-7:00 AM.): 9/9/14 @ 6:00 A.M.; 6/18/14 @ 6:00 A.M.; 3/19/14 @ 6:00 A.M.; and 12/6/13 @ 6:00 A.M.

As a result of the drill times being virtually the same for each of the quarterly drills performed, the conditions of the drills are not varied as required.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA 92B section 5.4.1 states that during the life of the building, maintenance is essential to ensure that the smoke management system will perform its intended function under fire conditions. Proper maintenance of the system should, as a minimum, include the periodic testing of all equipment, such as initiating devices, fans, dampers, controls, doors, and windows. The equipment should be maintained in accordance with the manufacturer ' s recommendations. (See NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, for suggested maintenance practices.)

Section 5.4.2 states the periodic tests should determine that the installed systems will continue to operate in accordance with the approved design. It is preferable to include in the tests both the measurements of airflow quantities and the pressure differentials at the following locations:
(1) Across smoke barrier openings
(2) At the air makeup supplies
(3) At smoke exhaust equipment
All data points should coincide with the acceptance test location to facilitate comparison measurements.

Section 5.4.3 states the system should be tested at least semiannually by persons who are thoroughly knowledgeable in the operation, testing, and maintenance of the systems. The results of the tests should be documented in the operations and maintenance log and made available for inspection. The smoke management system should be operated for each sequence in the current design criteria. The operation of the correct outputs for each given input should be observed. Tests, if applicable, should also be conducted under standby power.

THE FINDINGS INCLUDE:

While performing the record review of the fire alarm system on 11/18/14 at approximately 11:00 A.M., it was observed that the facility has no records documenting testing of the smoke evacuation system. It was stated by facility personnel that the facility was aware of the smoke evacuation system, but was unsure of when the last test/inspection was performed. The facility staff also stated that the fire alarm vendor did not currently test/inspect the smoke evacuation system because it was not written into the contract for testing.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. NFPA 101 2000 Edition Chapter 4 Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition.

NFPA 72, Section 7.3.2.1 1999 Edition 7-3.2.1 states detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Section 2-3.5.1 states in spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

1. A review of facility documentation made available on the morning of 11/18/14 indicates that smoke detector sensitivity testing had been conducted on a portion of the smoke detectors on 2/10/14 - 2/19/14 by Signet. Results of this testing indicate a total of five smoke detectors did not remain within their listed and marked sensitivity range. As a result, these detectors need to be cleaned and recalibrated or replaced. Neither of these corrective actions has been conducted as of the time of survey. (Note: It was indicated by facility personnel that the replacement of smoke detectors is included in the five year capital plan.)

2. The survey conducted 10/18/14 through 10/20/14 revealed numerous smoke detectors located throughout the facility which are located in direct airflow of the air supply diffusers. Smoke detectors should not be closer than 3 ft (1 m) from an air supply diffuser or return air opening in accordance with NFPA 72, Section 2-3..5.1.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. NFPA 101 2000 Edition Chapter 4 Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition.

NFPA 72, Section 7.3.2.1 1999 Edition 7-3.2.1 states detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

THE FINDINGS INCLUDE:

A review of facility documentation made available on the morning of 11/18/14 indicates that smoke detector sensitivity testing had been conducted on a portion of the smoke detectors on 2/12/14 and 5/8/14 by Signet. Results of this testing indicate a total of 16 smoke detectors did not remain within their listed and marked sensitivity range. As a result, these detectors need to be cleaned and recalibrated or replaced. Neither of these corrective actions has been conducted as of the time of survey. (Note: It was indicated by facility personnel that the replacement of smoke detectors is included in the five year capital plan.)

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. NFPA 101 2000 Edition Chapter 4 Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition.

NFPA 72, Section 7.3.2.1 1999 Edition 7-3.2.1 states detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
Section 2-3.5.1 states in spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

1. A review of facility documentation made available on the morning of 11/18/14 indicates that smoke detector sensitivity testing had been conducted on a portion of the smoke detectors on 2/10/14 - 2/19/14 and 5/7/14 - 5/12/14 by Signet. Results of this testing indicate a total of 32 smoke detectors did not remain within their listed and marked sensitivity range. As a result, these detectors need to be cleaned and recalibrated or replaced. Neither of these corrective actions has been conducted as of the time of survey. (Note: It was indicated by facility personnel that the replacement of smoke detectors is included in the five year capital plan.)

2. The survey conducted 10/18/14 through 10/20/14 revealed numerous smoke detectors located throughout the facility which are located in direct airflow of the air supply diffusers. Smoke detectors should not be closer than 3 ft (1 m) from an air supply diffuser or return air opening in accordance with NFPA 72, Section 2-3..5.1.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler heads are properly located in accordance with NFPA 13, 1999 Edition. Section 5-6.4.1.1 states under unobstructed construction, 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 made while touring the facility on 11/19/14 and 11/20/14 revealed that ceiling tiles had been removed in various areas throughout the building. The sprinkler protection that is provided is not properly located in accordance with NFPA 13, Section 5-6.4.1.1 due to the removal of suspended ceiling tiles leaving approximately 3 feet of space between the concrete deck above and the pendant sprinkler heads. Areas in which ceiling tiles are removed are as follows:

- the first floor bathroom located by the switchboard,
- the first floor cafeteria in the area by the Canteen,
- the basement housekeeping closet,
- the basement oxygen storage room, and
- the basement store room.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.

Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

NFPA #20 section 11-4 states periodic inspection, testing, and maintenance of
fire pumps shall be inspected, tested, and maintained in accordance with NFPA 25.

NFPA #25 section 5-3.2.2 states a weekly test of diesel engine-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically, and the pump shall run a minimum of 30 minutes.

Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.
Section 5-3.2.4.1 Pump System Procedure.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.
Section 5-3.2.4.2 Electrical System Procedure.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).
Section 5-3.2.4.3 Diesel Engine System Procedure.
(a) Observe the time for engine to crank.
(b) Observe the time for engine to reach running speed.
(c) Observe the engine oil pressure gauge, speed indicator, water, and oil temperature indicators periodically while engine is running.
(d) Record any abnormalities.
(e) Check the heat exchanger for cooling waterflow.

Section 9-3.4.1 states each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves (PIV) shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicating and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming.

Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, the following items were observed regarding the sprinkler system:

1) The sprinkler vendor inspection report dated 5/30/14 states the louvers allowing fresh air intake for the diesel fire pump are not operating as required. The louvers currently do not open automatically and must be opened manually upon operation of the pump. The facility staff stated they are aware of the problem and have contacted the appropriate vendor for repairs. As of the survey date of 11/20/14, the louvers are still not functioning as required.

2) After reviewing the fire pump log book, it was revealed that the pump is not tested and maintained as required. It was stated by staff that the fire pump is run for only 12-minutes per week because the test is performed flowing water. It was further stated that the the pump flows approximately 18,000 gallons of water during each weekly test. As a result of the large volume of water being flowed, the test is shut down before neighborhood streets are flooded.
In addition, the only documented inspection items during weekly testing of the pump is the date, time, suction and discharge pressures.

3) The main PIV to the facility is not tested annually as required. This valve which is located adjacent to the fire pump building is completely over grown with vines and weeds and can't be accessed. In addition, the vines were observed to wrap completely around the valve securing the handle to the main valve body.

4)The pressure gages on the wet pipe system are dated 1993. Facility engineering staff indicated that the sprinkler vendor said both system sets of gages are tested annually, however there is no documentation to substantiate that the gages were tested within the previous five years.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.

Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

NFPA #20 section 11-4 states periodic inspection, testing, and maintenance of
fire pumps shall be inspected, tested, and maintained in accordance with NFPA 25.

NFPA #25 section 5-3.2.2 states a weekly test of diesel engine-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically, and the pump shall run a minimum of 30 minutes.
Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.
Section 5-3.2.4.1 Pump System Procedure.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.
Section 5-3.2.4.2 Electrical System Procedure.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).
Section 5-3.2.4.3 Diesel Engine System Procedure.
(a) Observe the time for engine to crank.
(b) Observe the time for engine to reach running speed.
(c) Observe the engine oil pressure gauge, speed indicator, water, and oil temperature indicators periodically while engine is running.
(d) Record any abnormalities.
(e) Check the heat exchanger for cooling waterflow.

Section 9-3.4.1 states each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves (PIV) shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicating and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, the following items were observed regarding the sprinkler system:

1) The sprinkler vendor inspection report dated 5/30/14 states the louvers allowing fresh air intake for the diesel fire pump are not operating as required. The louvers currently do not open automatically and must be opened manually upon operation of the pump. The facility staff stated they are aware of the problem and have contacted the appropriate vendor for repairs. As of the survey date of 11/20/14, the louvers are still not functioning as required.

2) After reviewing the fire pump log book, it was revealed that the pump is not tested & maintained as required. It was stated by staff that the fire pump is run for only 12-minutes per week because the test is performed flowing water. It was further stated that the the pump flows approximately 18,000 gallons of water during each weekly test. As a result of the large volume of water being flowed, the test is shut down before neighborhood streets are flooded.
In addition, the only documented inspection items during weekly testing of the pump is the date, time, suction and discharge pressures.

3) The main PIV to the facility is not tested annually as required. This valve which is located adjacent to the fire pump building is completely over grown with vines and weeds and can't be accessed. In addition, the vines were observed to wrap completely around the valve securing the handle to the main valve body.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

A) Based on record review and observation, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. LSC Section 4.6.12.1 requires automatic sprinkler systems to be continuously maintained in proper operating condition.

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.

Sections 1.8 & 2.1.3 require records of inspections, tests and maintenance of the system and components be kept and made available to the authority having jurisdiction.

Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results and the date.

Section 9.4.4.2.2 requires each dry pipe valve to be trip tested annually during warm weather.
Section 9.4.4.2.2.1 requires dry pipe valves to be trip tested every 3 years with the control valve fully open.
Section 9.4.4.2.2.2 states " During those years when full flow testing in accordance with 9.4.4.2.2.1 is not required, each dry pipe valve shall be trip tested with the control valve partially open ."
Section 9.4.4.2.5 requires a tag or card showing the date on which the dry pipe valve was last tripped and showing the name of the person and organization conducting the test to be attached to the valve. Separate records of initial air and water pressure, tripping air pressure, and dry pipe valve operating condition shall be maintained on the premises for comparison with previous test results. Records of tripping time also shall be maintained for full flow trip tests.

Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years.

THE FINDINGS INCLUDE:

1. Record review of the quarterly automatic sprinkler system records available on 11/18/14 through 11/20/14 revealed that the required full flow trip tests of the dry system are not being done. The dry valve tag (located in the attic) indicates that only partial trip tests are conducted, and that only partial trip tests have been conducted since 11/6/08.
Facility engineering staff indicated that the sprinkler vendor said a full flow test was conducted the last couple of years, however there is no documentation to substantiate a full flow test was conducted during the previous three years.

2. The pressure gages on the wet pipe system are dated 1990 and the dry system pressure gages are dated 1992. Facility engineering staff indicated that the sprinkler vendor said both system sets of gages are tested annually, however there is no documentation to substantiate that the gages were tested within the previous five years.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.


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B) NFPA #20 section 11-4 states periodic inspection, testing, and maintenance of
fire pumps shall be inspected, tested, and maintained in accordance with NFPA 25.

NFPA #25 section 5-3.2.2 states a weekly test of diesel engine-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically, and the pump shall run a minimum of 30 minutes.
Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.
Section 5-3.2.4.1 Pump System Procedure.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.
Section 5-3.2.4.2 Electrical System Procedure.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).
Section 5-3.2.4.3 Diesel Engine System Procedure.
(a) Observe the time for engine to crank.
(b) Observe the time for engine to reach running speed.
(c) Observe the engine oil pressure gauge, speed indicator, water, and oil temperature indicators periodically while engine is running.
(d) Record any abnormalities.
(e) Check the heat exchanger for cooling waterflow.

Section 9-3.4.1 states each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves (PIV) shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicating and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, the following items were observed regarding the sprinkler system:

3) The sprinkler vendor inspection report dated 5/30/14 states the louvers allowing fresh air intake for the diesel fire pump are not operating as required. The louvers currently do not open automatically and must be opened manually upon operation of the pump. The facility staff stated they are aware of the problem and have contacted the appropriate vendor for repairs. As of the survey date of 11/20/14, the louvers are still not functioning as required.

4) After reviewing the fire pump log book, it was revealed that the pump is not tested and maintained as required. It was stated by staff that the fire pump is run for only 12-minutes per week because the test is performed flowing water. It was further stated that the the pump flows approximately 18,000 gallons of water during each weekly test. As a result of the large volume of water being flowed, the test is shut down before neighborhood streets are flooded.
In addition, the only documented inspection items during weekly testing of the pump is the date, time, suction and discharge pressures.

5) The main PIV to the facility is not tested annually as required. This valve which is located adjacent to the fire pump building is completely over grown with vines and weeds and can't be accessed. In addition, the vines were observed to wrap completely around the valve securing the handle to the main valve body.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
NOTE: The Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC announced a Categorical Waiver for Hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in Hospital heating and ventilating systems, so long as the Hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105.

THE FINDINGS INCLUDE:

While performing the building tour on 11/18/14, 11/19/14 and 11/20/14 it is noted that three (3) fire dampers located in the "A" stair on the second floor level, the "C" stair on the second floor level , and the "B" stair on the first floor level all have documented tags indicating the last fire damper inspection was conducted on 2/26/08. Record review of the most recent vendor fire damper inspection, conducted during August 2014, fails to specifically note the above devices being inspected during the previous four years. As a result, the fire dampers are approximately 6-months past due at this point in time for the 6-year test. In addition, the facility did not present the survey team with a categorical waiver requesting the 2-year extension of the testing of these devices. As a result, the facility is still under the 4-year testing cycle until an approved waiver application is accepted.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and observation, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. LSC Section 4.6.12.1 requires automatic sprinkler systems to be continuously maintained in proper operating condition.
NFPA #25,
Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years.


THE FINDINGS INCLUDE:

The pressure gages on the wet pipe system are dated 1999. Facility engineering staff indicated that the sprinkler vendor said both system sets of gages are tested annually, however there is no documentation to substantiate that the gages were tested within the previous five years.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff, the facility failed to ensure that the generator is run monthly under a load condition for the required 30-minutes.

NFPA 110 section 6-4.1 states level 1 and level 2 Emergency Power Supply Systems (EPSSs), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.

NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall 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
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, it was noted that the generator is not tested as required. After reviewing the generator log book, it was observed that the generator is not documented as having any substantiated load tests prior to 6/21/14. Prior to this June date, the facility documented testing by logging generator runs into a spiral notebook. However, the notebook simply states the date and time of the testing. There are no documented amperage readings to substantiate that the generator was being operated under a load condition. In addition, weekly inspection items such as oil pressure, water temperature, battery condition, etc, are not documented prior to the 6/21/14 inspection/test report.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff, the facility failed to ensure that the generator is run monthly under a load condition for the required 30-minutes. NFPA 110 section 6-4.1 states level 1 and level 2 Emergency Power Supply Systems (EPSSs), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.
NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall 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
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, it was noted that the generator is not tested as required. After reviewing the generator log book, it was observed that the generator is not documented as having any substantiated load tests prior to 6/21/14. Prior to this June date, the facility documented testing by logging generator runs into a spiral notebook. However, the notebook simply states the date and time of the testing. There are no documented amperage readings to substantiate that the generator was being operated under a load condition. In addition, weekly inspection items such as oil pressure, water temperature, battery condition, etc, are not documented prior to the 6/21/14 inspection/test report.
The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff, the facility failed to ensure that the generator is run monthly under a load condition for the required 30-minutes.

NFPA 110 section 6-4.1 states level 1 and level 2 Emergency Power Supply Systems (EPSSs), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.

NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall 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
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, it was noted that the generator is not tested as required. After reviewing the generator log book, it was observed that the generator is not documented as having any substantiated load tests prior to 6/21/14. Prior to this June date, the facility documented testing by logging generator runs into a spiral notebook. However, the notebook simply states the date and time of the testing. There are no documented amperage readings to substantiate that the generator was being operated under a load condition. In addition, weekly inspection items such as oil pressure, water temperature, battery condition, etc, are not documented prior to the 6/21/14 inspection/test report.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations, 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 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 or attached to building surfaces.
Article 300-15 requires electrical wiring to terminate in an approved box. LSC 19.5.1


THE FINDINGS INCLUDE:

On 11/18/14 the following was noted:

1. A strip type extension cord was utilized in the TERN Area's sensory room to supplement permanent wiring to a pedestal fan and a light.

2. An extension cord was utilized in the emergency electrical room (housing the emergency generator) to supplement power to a fan mounted behind the electric heater.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations, the facility failed to properly install alcohol based hand rub (ABHR) dispensers.

THE FINDINGS INCLUDE

On 11/19/14 it was noted that an alcohol based hand rub (ABHR) was installed above a light toggle switch in the basement clinic.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure corridor walls are constructed as required. Exception No. 6 to 19.3.6.1 states spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

THE FINDINGS INCLUDE:

1. While surveying at approximately 12:00 P.M. on 11/19/14, it was noted that a four inch flexible plastic exhaust duct penetrated the corridor wall, above the suspended ceiling, from the bathroom of room 142 to the corridor. The duct terminated at the fire barrier doors which lead from the Besse to the Glass Building. This negates the required 1/2 hour fire resistance rating of the corridor wall.

2. While touring the facility on 11/18/14 it was observed that the chapel located on the first floor is not provided with corridor walls as required by Section 19.3.6.1 nor does the chapel meet Exception No. 6 to 19.3.6.1 which requires the open space to be protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.

The findings were confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations, the facility failed to ensure that doors protecting corridor openings are in compliance with section 19.3.6.3.

THE FINDINGS INCLUDE:

1) While touring the facility on 11/18/14, it was observed that the basement level patient lounge/activity room (labeled G27) corridor doors have a 1/4" gap at the meeting edge of the doors.


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2) While performing the building tour on both 11/18/14 and 11/19/14, it was observed that the majority of all the patient room doors are not maintained as required. The dual action doors were originally designed with recessed door gaskets on the latching side. This felt strip gasket is attached to an aluminum backing which is recessed into the door edge. The gaskets which are missing from the majority of all the patient room doors are either missing in their entirety or partially missing in each of the units surveyed. In addition, the latching mechanisms are also broken on the majority of the doors in each of the units surveyed. The latching mechanisms are mostly stuck in the retracted position and can no longer achieve positive latching as required. As a result of these issues, the doors are not capable of resisting the passage of smoke.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier walls are properly maintained.

THE FINDINGS INCLUDE:

While performing the building tour on 11/19/14 at approximately 11:00 A.M., it was observed that the 3rd floor smoke barrier is not properly maintained. The smoke wall above the ceiling tiles located within the laundry room has a void around a duct penetration. There is a smoke damper installed on the duct, the damper is recessed into the wall with an approximate 4" x 6" opening around the damper. The wall in this location is not smoke tight as there are gaps through the entire depth of the wall around the damper/duct.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

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

THE FINDINGS INCLUDE:

1. While performing the building tour on 11/18/14 and 11/19/14, it was observed that the trash room doors on the both the 4th & 3rd floor levels are not equipped with self closing devices. These rooms are considered hazardous areas and are required to be separated from the corridors with self closing/latching doors.

2. The non-sprinklered emergency electrical room, which also houses the emergency generator, has unsealed corridor wall penetrations around electrical conduit and piping.

3. The Mechanical Room (labeled G4) has unsealed corridor wall penetrations around electrical, gas, chilled water and sprinkler piping.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations, the facility failed to ensure that hazardous areas are enclosed as required. NFPA 101 Life Safety Code 2000 Edition Chapter 19 Section 19.3.2.1 Hazardous Areas states any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction

THE FINDINGS INCLUDE:

Observations during a tour of the facility in the afternoon of 11/18/14 hours revealed that hazardous areas are not provided with smoke resistant construction as evidenced by the following:

1. The single corridor door to the kitchen was not smoke tight due to various voids in the door around the door knob where hardware had been previously removed.

2. The corridor door to the basement mechanical room was not smoke tight due to a louver, which was equipped with a fire damper, in the door. The corridor door to the mechanical room is required to resist the passage of smoke.

3. The basement Store Room was not smoke tight due to a void around the 4 inch waste line which penetrates the wall to the delivery access area.

4. One of three corridor doors to the basement Store Room was not self closing due to the door being equipped with a self chalking closing device which allows the door to remain in the open position.

5. One of the three corridor doors to the basement Store Room was equipped with a kick stop which also allows the door to remain in the open position.

The finding was confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations, the facility failed to ensure that exit stairways are enclosed as required.

THE FINDINGS INCLUDE:

Observations while touring the facility on 11/18/14 and 11/19/14 revealed that:

Each of the "A", "B" "C" , and "D"stairs accessible from the nursing units on the basement level and first floor level have unsealed penetrations or section of block removed from the stair enclosure. This is visible on the corridor side of the stair above the in-lay ceiling tiles (as the ceiling in the stair is monolithic).
Most notably at the following locations:
-"C" stair basement level where a 28" x 16" section of block is missing.
- "A" stair basement level where two unsealed pipe penetrations are noted.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations, the facility failed to ensure that the discharge from exits is in accordance with Chapter 7. Section 7.1.10.1 requires every exit, exit access and exit discharge to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.7.1 requires exits to terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 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.

THE FINDINGS INCLUDE:

While touring the facility on 11/18/14 through 11/20/14 it was observed that the exit discharge from Stair A does not terminate at the public way. It terminates onto a concrete landing and a grass walking surface.

The finding was reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure egress doors are maintained as required. Section 19.2.2.2.4 states doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side. Section 7.2.1.5.1 states doors shall 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.

THE FINDINGS INCLUDE:

While performing the 3-East tour on 11/19/14 at approximately 11:30 A.M., it was observed that each patient room has been converted to office spaces. The original doors and locking mechanisms are still currently in use in these office locations. The doors are equipped with keyed locks from the corridor side only, with no method of release from the egress side of the door. The locks do not meet any code exceptions as the rooms are no longer used for patient care meeting the clinical needs of the patients. Each door has the capability of being locked allowing no egress from the room side as required.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. Section 7.2.4.3.7 requires doors in horizontal exits to be designed and installed to minimize air leakage

THE FINDINGS INCLUDE:

During the morning hours on 11/19/14 while touring the facility, it was observed that the 2 hour fire resistance rating of the fire barrier walls was not maintained above the suspended ceilings in the following areas:

1. The basement level fire barrier located between the Besse and Glass Buildings, in the location of the fire barrier doors, was not maintained as evidenced by voids around two 4" conduits.

2. The basement level fire barrier located between the Besse and Chambers Buildings, in the location of the fire barrier doors, was not maintained as evidenced by a 4" x 4" and 3" x 4" voids and gaps within the 5" cored holes.

Due to these voids, the fire rating of the fire barrier wall is not maintained.

The finding was confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. Section 7.2.4.3.7 requires doors in horizontal exits to be designed and installed to minimize air leakage

THE FINDINGS INCLUDE:

During the morning hours on 11/19/14 while touring the facility, it was observed that the 2 hour fire resistance rating of the fire barrier walls was not maintained above the suspended ceilings in the following areas:

1. The basement level fire barrier located between the Besse and Glass Buildings, in the location of the fire barrier doors, was not maintained as evidenced by voids around two 4" conduits.

2. The first floor fire barrier wall between the kitchen utility closet and the Chambers Building was not maintained as evidenced by voids around various piping.

Due to these voids, the fire rating of the fire barrier wall is not maintained.

The finding was confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 states artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.

Section 7.8.1.4 states required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

THE FINDINGS INCLUDE:

Observations while touring the facility on 11/20/14 revealed that the artificial lighting in Stair A was not functioning, leaving all levels of the stair without adequate illumination.
.
The finding was confirmed by facility personnel during the survey and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that exit signs are properly maintained.
Section 7.10.1.2 states exits other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
Section 7.10.6.1 states externally illuminated signs required by 7.10.1 and 7.10.2, other than approved existing signs, shall have the word EXIT or other appropriate wording in plainly legible letters not less than 6 in. (15.2 cm) high with the principal strokes of letters not less than 3/4 in. (1.9 cm) wide. The word EXIT shall have letters of a width not less than 2 in. (5 cm), except the letter I, and the minimum spacing between letters shall be not less than 3/8 in. (1 cm). Signs larger than the minimum established in this paragraph shall have letter widths, strokes, and spacing in proportion to their height.

THE FINDINGS INCLUDE:

During the afternoon hours of 11/19/14 at approximately 2:00 P.M., the exit sign above stairwell #1 door on the 3-West unit was observed as missing. It was stated by facility staff that the sign was vandalized and removed by a disruptive patient.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted as required.

THE FINDINGS INCLUDE:

During the afternoon hours of 11/19/14, the facility's documentation regarding fire drills was reviewed for code compliance. During review, it was noted that the fire drills are not performed as required. Although the facility is meeting the minimum requirements for the amounts of drills performed, the drills conducted are not varying the conditions as required. The drills are documented as follows:

1st Shift (7:00 A.M.-3:00 P.M.): 11/13/14 @ 10:00 A.M.; 8/6/14 @ 10:00 A.M.; 5/7/14 @ 10:00 A.M.; and 3/4/14 @ 10:15 A.M.

2nd Shift (3:00 P.M.-11:00P.M.): 10/8/14 @ 4:00 P.M.; 7/2/14 @ 4:20 P.M.; 6/11/14 @ 4:00 P.M.; 4/8/14 @ 4:00 P.M.; 2/20/14 @ 4:00 P.M.;and 10/3/13 @ 4:00 P.M.

3rd Shift (11:00 P.M.-7:00 AM.): 9/9/14 @ 6:00 A.M.; 6/18/14 @ 6:00 A.M.; 3/19/14 @ 6:00 A.M.; and 12/6/13 @ 6:00 A.M.

As a result of the drill times being virtually the same for each of the quarterly drills performed, the conditions of the drills are not varied as required.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted as required.

THE FINDINGS INCLUDE:

During the afternoon hours of 11/19/14, the facility's documentation regarding fire drills was reviewed for code compliance. During review, it was noted that the fire drills are not performed as required. Although the facility is meeting the minimum requirements for the amounts of drills performed, the drills conducted are not varying the conditions as required. The drills are documented as follows:

1st Shift (7:00 A.M.-3:00 P.M.): 11/13/14 @ 10:00 A.M.; 8/6/14 @ 10:00 A.M.; 5/7/14 @ 10:00 A.M.; and 3/4/14 @ 10:15 A.M.

2nd Shift (3:00 P.M.-11:00 P.M.): 10/8/14 @ 4:00 P.M.; 7/2/14 @ 4:20 P.M.; 6/11/14 @ 4:00 P.M.; 4/8/14 @ 4:00 P.M.; 2/20/14 @ 4:00 P.M.;and 10/3/13 @ 4:00 P.M.

3rd Shift (11:00 P.M.-7:00 AM.): 9/9/14 @ 6:00 A.M.; 6/18/14 @ 6:00 A.M.; 3/19/14 @ 6:00 A.M.; and 12/6/13 @ 6:00 A.M.

As a result of the drill times being virtually the same for each of the quarterly drills performed, the conditions of the drills are not varied as required.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA 92B section 5.4.1 states that during the life of the building, maintenance is essential to ensure that the smoke management system will perform its intended function under fire conditions. Proper maintenance of the system should, as a minimum, include the periodic testing of all equipment, such as initiating devices, fans, dampers, controls, doors, and windows. The equipment should be maintained in accordance with the manufacturer ' s recommendations. (See NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, for suggested maintenance practices.)

Section 5.4.2 states the periodic tests should determine that the installed systems will continue to operate in accordance with the approved design. It is preferable to include in the tests both the measurements of airflow quantities and the pressure differentials at the following locations:
(1) Across smoke barrier openings
(2) At the air makeup supplies
(3) At smoke exhaust equipment
All data points should coincide with the acceptance test location to facilitate comparison measurements.

Section 5.4.3 states the system should be tested at least semiannually by persons who are thoroughly knowledgeable in the operation, testing, and maintenance of the systems. The results of the tests should be documented in the operations and maintenance log and made available for inspection. The smoke management system should be operated for each sequence in the current design criteria. The operation of the correct outputs for each given input should be observed. Tests, if applicable, should also be conducted under standby power.

THE FINDINGS INCLUDE:

While performing the record review of the fire alarm system on 11/18/14 at approximately 11:00 A.M., it was observed that the facility has no records documenting testing of the smoke evacuation system. It was stated by facility personnel that the facility was aware of the smoke evacuation system, but was unsure of when the last test/inspection was performed. The facility staff also stated that the fire alarm vendor did not currently test/inspect the smoke evacuation system because it was not written into the contract for testing.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. NFPA 101 2000 Edition Chapter 4 Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition.

NFPA 72, Section 7.3.2.1 1999 Edition 7-3.2.1 states detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Section 2-3.5.1 states in spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

1. A review of facility documentation made available on the morning of 11/18/14 indicates that smoke detector sensitivity testing had been conducted on a portion of the smoke detectors on 2/10/14 - 2/19/14 by Signet. Results of this testing indicate a total of five smoke detectors did not remain within their listed and marked sensitivity range. As a result, these detectors need to be cleaned and recalibrated or replaced. Neither of these corrective actions has been conducted as of the time of survey. (Note: It was indicated by facility personnel that the replacement of smoke detectors is included in the five year capital plan.)

2. The survey conducted 10/18/14 through 10/20/14 revealed numerous smoke detectors located throughout the facility which are located in direct airflow of the air supply diffusers. Smoke detectors should not be closer than 3 ft (1 m) from an air supply diffuser or return air opening in accordance with NFPA 72, Section 2-3..5.1.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. NFPA 101 2000 Edition Chapter 4 Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition.

NFPA 72, Section 7.3.2.1 1999 Edition 7-3.2.1 states detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

THE FINDINGS INCLUDE:

A review of facility documentation made available on the morning of 11/18/14 indicates that smoke detector sensitivity testing had been conducted on a portion of the smoke detectors on 2/12/14 and 5/8/14 by Signet. Results of this testing indicate a total of 16 smoke detectors did not remain within their listed and marked sensitivity range. As a result, these detectors need to be cleaned and recalibrated or replaced. Neither of these corrective actions has been conducted as of the time of survey. (Note: It was indicated by facility personnel that the replacement of smoke detectors is included in the five year capital plan.)

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. NFPA 101 2000 Edition Chapter 4 Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition.

NFPA 72, Section 7.3.2.1 1999 Edition 7-3.2.1 states detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
Section 2-3.5.1 states in spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

1. A review of facility documentation made available on the morning of 11/18/14 indicates that smoke detector sensitivity testing had been conducted on a portion of the smoke detectors on 2/10/14 - 2/19/14 and 5/7/14 - 5/12/14 by Signet. Results of this testing indicate a total of 32 smoke detectors did not remain within their listed and marked sensitivity range. As a result, these detectors need to be cleaned and recalibrated or replaced. Neither of these corrective actions has been conducted as of the time of survey. (Note: It was indicated by facility personnel that the replacement of smoke detectors is included in the five year capital plan.)

2. The survey conducted 10/18/14 through 10/20/14 revealed numerous smoke detectors located throughout the facility which are located in direct airflow of the air supply diffusers. Smoke detectors should not be closer than 3 ft (1 m) from an air supply diffuser or return air opening in accordance with NFPA 72, Section 2-3..5.1.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler heads are properly located in accordance with NFPA 13, 1999 Edition. Section 5-6.4.1.1 states under unobstructed construction, 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 made while touring the facility on 11/19/14 and 11/20/14 revealed that ceiling tiles had been removed in various areas throughout the building. The sprinkler protection that is provided is not properly located in accordance with NFPA 13, Section 5-6.4.1.1 due to the removal of suspended ceiling tiles leaving approximately 3 feet of space between the concrete deck above and the pendant sprinkler heads. Areas in which ceiling tiles are removed are as follows:

- the first floor bathroom located by the switchboard,
- the first floor cafeteria in the area by the Canteen,
- the basement housekeeping closet,
- the basement oxygen storage room, and
- the basement store room.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.

Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

NFPA #20 section 11-4 states periodic inspection, testing, and maintenance of
fire pumps shall be inspected, tested, and maintained in accordance with NFPA 25.

NFPA #25 section 5-3.2.2 states a weekly test of diesel engine-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically, and the pump shall run a minimum of 30 minutes.

Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.
Section 5-3.2.4.1 Pump System Procedure.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.
Section 5-3.2.4.2 Electrical System Procedure.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).
Section 5-3.2.4.3 Diesel Engine System Procedure.
(a) Observe the time for engine to crank.
(b) Observe the time for engine to reach running speed.
(c) Observe the engine oil pressure gauge, speed indicator, water, and oil temperature indicators periodically while engine is running.
(d) Record any abnormalities.
(e) Check the heat exchanger for cooling waterflow.

Section 9-3.4.1 states each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves (PIV) shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicating and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming.

Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, the following items were observed regarding the sprinkler system:

1) The sprinkler vendor inspection report dated 5/30/14 states the louvers allowing fresh air intake for the diesel fire pump are not operating as required. The louvers currently do not open automatically and must be opened manually upon operation of the pump. The facility staff stated they are aware of the problem and have contacted the appropriate vendor for repairs. As of the survey date of 11/20/14, the louvers are still not functioning as required.

2) After reviewing the fire pump log book, it was revealed that the pump is not tested and maintained as required. It was stated by staff that the fire pump is run for only 12-minutes per week because the test is performed flowing water. It was further stated that the the pump flows approximately 18,000 gallons of water during each weekly test. As a result of the large volume of water being flowed, the test is shut down before neighborhood streets are flooded.
In addition, the only documented inspection items during weekly testing of the pump is the date, time, suction and discharge pressures.

3) The main PIV to the facility is not tested annually as required. This valve which is located adjacent to the fire pump building is completely over grown with vines and weeds and can't be accessed. In addition, the vines were observed to wrap completely around the valve securing the handle to the main valve body.

4)The pressure gages on the wet pipe system are dated 1993. Facility engineering staff indicated that the sprinkler vendor said both system sets of gages are tested annually, however there is no documentation to substantiate that the gages were tested within the previous five years.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and records provided, the facility failed to properly maintain the sprinkler system. NFPA #25 section 1-4.2 states the responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.

Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

NFPA #20 section 11-4 states periodic inspection, testing, and maintenance of
fire pumps shall be inspected, tested, and maintained in accordance with NFPA 25.

NFPA #25 section 5-3.2.2 states a weekly test of diesel engine-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically, and the pump shall run a minimum of 30 minutes.
Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.
Section 5-3.2.4.1 Pump System Procedure.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.
Section 5-3.2.4.2 Electrical System Procedure.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).
Section 5-3.2.4.3 Diesel Engine System Procedure.
(a) Observe the time for engine to crank.
(b) Observe the time for engine to reach running speed.
(c) Observe the engine oil pressure gauge, speed indicator, water, and oil temperature indicators periodically while engine is running.
(d) Record any abnormalities.
(e) Check the heat exchanger for cooling waterflow.

Section 9-3.4.1 states each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves (PIV) shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicating and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, the following items were observed regarding the sprinkler system:

1) The sprinkler vendor inspection report dated 5/30/14 states the louvers allowing fresh air intake for the diesel fire pump are not operating as required. The louvers currently do not open automatically and must be opened manually upon operation of the pump. The facility staff stated they are aware of the problem and have contacted the appropriate vendor for repairs. As of the survey date of 11/20/14, the louvers are still not functioning as required.

2) After reviewing the fire pump log book, it was revealed that the pump is not tested & maintained as required. It was stated by staff that the fire pump is run for only 12-minutes per week because the test is performed flowing water. It was further stated that the the pump flows approximately 18,000 gallons of water during each weekly test. As a result of the large volume of water being flowed, the test is shut down before neighborhood streets are flooded.
In addition, the only documented inspection items during weekly testing of the pump is the date, time, suction and discharge pressures.

3) The main PIV to the facility is not tested annually as required. This valve which is located adjacent to the fire pump building is completely over grown with vines and weeds and can't be accessed. In addition, the vines were observed to wrap completely around the valve securing the handle to the main valve body.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

A) Based on record review and observation, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. LSC Section 4.6.12.1 requires automatic sprinkler systems to be continuously maintained in proper operating condition.

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.

Sections 1.8 & 2.1.3 require records of inspections, tests and maintenance of the system and components be kept and made available to the authority having jurisdiction.

Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results and the date.

Section 9.4.4.2.2 requires each dry pipe valve to be trip tested annually during warm weather.
Section 9.4.4.2.2.1 requires dry pipe valves to be trip tested every 3 years with the control valve fully open.
Section 9.4.4.2.2.2 states " During those years when full flow testing in accordance with 9.4.4.2.2.1 is not required, each dry pipe valve shall be trip tested with the control valve partially open ."
Section 9.4.4.2.5 requires a tag or card showing the date on which the dry pipe valve was last tripped and showing the name of the person and organization conducting the test to be attached to the valve. Separate records of initial air and water pressure, tripping air pressure, and dry pipe valve operating condition shall be maintained on the premises for comparison with previous test results. Records of tripping time also shall be maintained for full flow trip tests.

Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years.

THE FINDINGS INCLUDE:

1. Record review of the quarterly automatic sprinkler system records available on 11/18/14 through 11/20/14 revealed that the required full flow trip tests of the dry system are not being done. The dry valve tag (located in the attic) indicates that only partial trip tests are conducted, and that only partial trip tests have been conducted since 11/6/08.
Facility engineering staff indicated that the sprinkler vendor said a full flow test was conducted the last couple of years, however there is no documentation to substantiate a full flow test was conducted during the previous three years.

2. The pressure gages on the wet pipe system are dated 1990 and the dry system pressure gages are dated 1992. Facility engineering staff indicated that the sprinkler vendor said both system sets of gages are tested annually, however there is no documentation to substantiate that the gages were tested within the previous five years.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.


16934

B) NFPA #20 section 11-4 states periodic inspection, testing, and maintenance of
fire pumps shall be inspected, tested, and maintained in accordance with NFPA 25.

NFPA #25 section 5-3.2.2 states a weekly test of diesel engine-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically, and the pump shall run a minimum of 30 minutes.
Section 5-3.2.4 states the pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running.
Section 5-3.2.4.1 Pump System Procedure.
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.
Section 5-3.2.4.2 Electrical System Procedure.
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic stop controllers).
Section 5-3.2.4.3 Diesel Engine System Procedure.
(a) Observe the time for engine to crank.
(b) Observe the time for engine to reach running speed.
(c) Observe the engine oil pressure gauge, speed indicator, water, and oil temperature indicators periodically while engine is running.
(d) Record any abnormalities.
(e) Check the heat exchanger for cooling waterflow.

Section 9-3.4.1 states each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves (PIV) shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicating and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, the following items were observed regarding the sprinkler system:

3) The sprinkler vendor inspection report dated 5/30/14 states the louvers allowing fresh air intake for the diesel fire pump are not operating as required. The louvers currently do not open automatically and must be opened manually upon operation of the pump. The facility staff stated they are aware of the problem and have contacted the appropriate vendor for repairs. As of the survey date of 11/20/14, the louvers are still not functioning as required.

4) After reviewing the fire pump log book, it was revealed that the pump is not tested and maintained as required. It was stated by staff that the fire pump is run for only 12-minutes per week because the test is performed flowing water. It was further stated that the the pump flows approximately 18,000 gallons of water during each weekly test. As a result of the large volume of water being flowed, the test is shut down before neighborhood streets are flooded.
In addition, the only documented inspection items during weekly testing of the pump is the date, time, suction and discharge pressures.

5) The main PIV to the facility is not tested annually as required. This valve which is located adjacent to the fire pump building is completely over grown with vines and weeds and can't be accessed. In addition, the vines were observed to wrap completely around the valve securing the handle to the main valve body.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA 90A. NFPA 90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.
NOTE: The Centers for Medicare and Medicaid Services (CMS) S&C-10-04-LSC announced a Categorical Waiver for Hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in Hospital heating and ventilating systems, so long as the Hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105.

THE FINDINGS INCLUDE:

While performing the building tour on 11/18/14, 11/19/14 and 11/20/14 it is noted that three (3) fire dampers located in the "A" stair on the second floor level, the "C" stair on the second floor level , and the "B" stair on the first floor level all have documented tags indicating the last fire damper inspection was conducted on 2/26/08. Record review of the most recent vendor fire damper inspection, conducted during August 2014, fails to specifically note the above devices being inspected during the previous four years. As a result, the fire dampers are approximately 6-months past due at this point in time for the 6-year test. In addition, the facility did not present the survey team with a categorical waiver requesting the 2-year extension of the testing of these devices. As a result, the facility is still under the 4-year testing cycle until an approved waiver application is accepted.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and observation, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required by NFPA #25. LSC Section 4.6.12.1 requires automatic sprinkler systems to be continuously maintained in proper operating condition.
NFPA #25,
Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years.


THE FINDINGS INCLUDE:

The pressure gages on the wet pipe system are dated 1999. Facility engineering staff indicated that the sprinkler vendor said both system sets of gages are tested annually, however there is no documentation to substantiate that the gages were tested within the previous five years.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff, the facility failed to ensure that the generator is run monthly under a load condition for the required 30-minutes.

NFPA 110 section 6-4.1 states level 1 and level 2 Emergency Power Supply Systems (EPSSs), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.

NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall 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
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, it was noted that the generator is not tested as required. After reviewing the generator log book, it was observed that the generator is not documented as having any substantiated load tests prior to 6/21/14. Prior to this June date, the facility documented testing by logging generator runs into a spiral notebook. However, the notebook simply states the date and time of the testing. There are no documented amperage readings to substantiate that the generator was being operated under a load condition. In addition, weekly inspection items such as oil pressure, water temperature, battery condition, etc, are not documented prior to the 6/21/14 inspection/test report.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff, the facility failed to ensure that the generator is run monthly under a load condition for the required 30-minutes. NFPA 110 section 6-4.1 states level 1 and level 2 Emergency Power Supply Systems (EPSSs), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.
NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall 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
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, it was noted that the generator is not tested as required. After reviewing the generator log book, it was observed that the generator is not documented as having any substantiated load tests prior to 6/21/14. Prior to this June date, the facility documented testing by logging generator runs into a spiral notebook. However, the notebook simply states the date and time of the testing. There are no documented amperage readings to substantiate that the generator was being operated under a load condition. In addition, weekly inspection items such as oil pressure, water temperature, battery condition, etc, are not documented prior to the 6/21/14 inspection/test report.
The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on record review and confirmed by staff, the facility failed to ensure that the generator is run monthly under a load condition for the required 30-minutes.

NFPA 110 section 6-4.1 states level 1 and level 2 Emergency Power Supply Systems (EPSSs), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.

NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall 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
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

During the morning hours of 11/18/14 at approximately 10:30 A.M. while performing the record review process, it was noted that the generator is not tested as required. After reviewing the generator log book, it was observed that the generator is not documented as having any substantiated load tests prior to 6/21/14. Prior to this June date, the facility documented testing by logging generator runs into a spiral notebook. However, the notebook simply states the date and time of the testing. There are no documented amperage readings to substantiate that the generator was being operated under a load condition. In addition, weekly inspection items such as oil pressure, water temperature, battery condition, etc, are not documented prior to the 6/21/14 inspection/test report.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.

Based on observations, 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 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 or attached to building surfaces.
Article 300-15 requires electrical wiring to terminate in an approved box. LSC 19.5.1


THE FINDINGS INCLUDE:

On 11/18/14 the following was noted:

1. A strip type extension cord was utilized in the TERN Area's sensory room to supplement permanent wiring to a pedestal fan and a light.

2. An extension cord was utilized in the emergency electrical room (housing the emergency generator) to supplement power to a fan mounted behind the electric heater.

The finding was confirmed by facility personnel and reviewed with administration during the exit conference.