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r E IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINNELL, LP, Plaintiff. vs. Cavil Action No. FOX SUBACUTE AT MECHANICSBURG, LLC, Defendant. COMPLAINT IN CIVIL ACTION FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: SHAWN P. MCCLURE, ESQUIRE PA ID #205951 JENNIFER L. TIS, ESQUIRE PA ID #203751 RAYMOND P. WENDOLOWSKI, JR., ESQUIRE PA ID #311415 Bernstein- Burkley, P.C. Firm #718 Suite 2200 Gulf Tower Pittsburgh, PA 15219 412- 456 -8100 BERNSTEIN FILE NO. C00772-46 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINNELL, LP, Plaintiff, vs. Civil Action No. FOX SUBACUTE AT MECHANICSBURG. LLC, Defendant. NOTICE AND COMPLAINT NOTICE TO DEFEND You have been sued in Court. If you wish to defend against the claims set forth in the following pages. you must take action within twenty (20) days after this Complaint and Notice are served upon you, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a Judgment may be entered against you by the Court, without further notice, for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDF? YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 717- 249 -3166 800 - 990 -9108 2 00077246 COMPLAINT I . Plaintiff, SimplexGrinnell ( "Plaintiff'), is a limited partnership with offices at 283 Gibraltar Road, Horsham, Pennsylvania 19044. 2. Defendant, Fox Subacute at Mechanicsburg, LLC ( "Defendant "), is a limited liability company having offices and place of business at 120 S. Filbert Street, Mechanicsburg, Cumberland County, Pennsylvania 17055. 3. On or about September 6, 2012, Plaintiff provided Defendant with professional services per the attached Service Request ( "Agreement "), a true and correct copy of which is attached hereto, marked Exhibit " I and made a part hereof. -l. At the special instance and request of Defendant, Plaintiff provided professional services to Defendant. as is more specifically shown by Plaintiffs Invoices, true and correct copies of which are attached hereto, marked Exhibit "2" collectively, and made a part hereof. 5. Defendant received and accepted the aforementioned professional services. �. The prices charged by Plaintiff were the fair, reasonable, and market prices that prevailed at the times of the transactions. The prices charged by Plaintiff were the prices that Defendant agreed to pay. 8. Plaintiff avers that as of September 21, 2012, a balance of $5,627.18, plus interest in the amount of $168.82. for a total of $5,796.00 due and owing to Plaintiff as a result of the Defendant's failure to pay for the aforementioned professional services. Q. Plaintiff avers that the Agreement between the parties provides for legal interest at the rate of six percent (6 per annum as damages on the liquidated balance. 10. Plaintiff avers that the Agreement between the parties provides that Defendant will pay Plaintiff's collection costs (including reasonable attorneys' fees). 3 Ca»7246 1 1. Plaintiff avers that such reasonable collection costs (including reasonable attorneys' fees) will amount to $1,873.85. 12. Although repeatedly requested to do so by Plaintiff, Defendant has willfully failed and refused to pay the aforesaid balance, legal interest, attorneys' fees, or any part thereof to Plaintiff. WHEREFORE, Plaintiff demands Judgment against Defendant, Fox Subacute at Mechanicsburg, L-C, in the amount of $7,669.85, with continuing legal interest on the principal balance at the rate of six percent (6 %), and costs. BERNSTEIN-BURKLEY, P.C. '- By: ; Raymon P. Wendolowski, Jr., Esquire PA ID #311415 Attorney for Plaintiff 707 Grant Street Suite 2200 - Gulf Tower Pittsburgh, PA 15219 412- 456 -8100 BERNSTEIN FILE NO. C0077246 4 C0077240 S�'rnp /e�ir6 ape/! SERVICE REQUEST FbRWARD TO YOUR PAYABLE DEPARTMENT eoo < a `. .... ................ ........ BE SAFE. ATyco 1"tarrrational Company TR* 1 13 TASWCA 3 r ( 3 4700 Suite 18W ; uc isE a PROJECT* v 3 Machankabl>,g„ PA 7 7OW NAME _f P' 717- 6tQ.gi Ti F 717.r aoORESS (0 ATYLFlIpN "PUT CUSTOMER STAMP ON ALL 3 PAGES' I LABOR -� r LnBOR.- OI L/1BCA - F)'f AWnSS I CrTy t ... VEI-- REm TKAvm _ 107 "tHgV�, - AT J i �} 21P. � MIN. IN9P,� MONFy � � Ra AFir7VAL DATE Bkt_ NDM -9ILL. - . (iLM7PL ACE COD$ NAT. ACCT d ) • PRONE � MRCS- NAmE (m Tor I r I + ! � Lew -Rm TRAY - REG LOR - OT i AyF11 .L _ _ City v- or v. I. aufh -lZe Sirop%xGriruneff to Proceed vvjtft the work: as agreed to and outffned below: r Customer sfDnaE:+rte Y j PAYMENT TERMS Hate ? 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SIM♦sf- Aff�Nia L f_P @ 54 mp1eaYLihtiWl LP 2pC7 ltlre MW nee 141 7 Ngkts reserves ih IPnnr N�1 i - — ._ .. 151.mprerp+nrselt Repnr,� $erv-,� r�egJesr Form '- ntc:•plrr �zr,,.• EXHIBIT ' 1.1 N 's b 00 4 a U A W N iP 6� g fir m g p 11 tA rr , s I a , al a �- �R6 a' a ir w Simp/exGrinne// FIRE ALARM INSPECTION REPORT August 2012 Inspection PREPARED FOR Bill Haig Dir. Environmental Svcs Fox Subacute at Mechanicsburg 120 South Filbert Street Mechanicsburg, PA 17055 -6539 ( 458 -0932 09/06/2012 SimplexGrinnell SimplexGrinnell FIRE ALARM INSPECTION REPORT SITE: Fox Subacute at Mechanicsburg TABLE OF CONTENTS Test Summary I Monitoring/jurisdictional Agencies 2 Test Results - Control Panel/Central Processing Unit 3 Test Results - Alarm Initiating Devices 7 Test Results - Alarm Indicating Devices 19 Sensitivity Test Results 20 Inspection Deficiencies Summary 25 SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 1 Bill Haig Dir. Environmental Svcs Fox Subacute at Mechanicsburg 120 South Filbert Street Mechanicsburg, PA 17055 -6539 Thank you for choosing SimplexGrinnell as the provider of your Fire Alarm Inspection services, which began on August 24, 2012, and were completed on September 6, 2012. This was the annual functional test of the fire alarm system as prescribed by the testing frequencies established in NFPA72, 1999 edition. Tested and cleaned all initiating devices as listed throughout the detail results of the inspection report. Smoke detector sensitivity was tested to ensure proper detection levels. Performed control panel and backup battery tests. Tested the following auxiliary functions: -Door holders- verified magnetic door hold, release and complete closure in an alarm condition. -AHU Shutdown- verified shutdown of air handler units with an alarm of attached duct detector. - Magnetic Lock Release- verified release of secured doors in an alarm condition. Alarm notification appliances were tested throughout the building. Verified that alarm and trouble signals were received by the outside monitoring agency (via customer). No failures or deficiencies were noted during this inspection. Annual Inspection Schedule: August -100% Test & Clean 100% Sensitivity in EVEN years February- Visual Inspection SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 2 SITE: Fox Subacute at Mechanicsburg Monitoring Agency: Tyco Security Solutions Authority Having Jurisdiction: Inspection Service: SimplexGrinnell 4700 Westport Dr. Suite 1800 Mechanicsburg, PA, 17055 Phone: (717) 610 -8111 Fax: (717) 610.8101 Office: (717) 610 -8100 K. Saltzburg - repairs: (717) 610 -8119 M. Smith - inspector: (717) 982 -0872 License No.: Service Mgr: Ken Bogue Service Sales: Sheron Chase Inspector: Matt Smith Inspector: Joe Bair SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 3 SITE: Fox Subacute at Mechanicsburg CONTROL PANEL/CENTRAL PROCESSING UNIT Simplex 2120 -8212 Serial # V92958 Building: Main Building Floor: 01 Area: Nurses Office by Main Ent. Test Performed Result Value Notes Voltage w/ Charger Passed 27.5 Voltage w/o Charger Passed 25.6 Battery % of Charge Passed 90.0 Battery Age Check Passed Control Function(s) Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 4 SITE: Fox Subacute at Mechanicsburg CONTROL PANEL/CENTRAL PROCESSING UNIT Simplex 4009 Serial # H9388712 Building: Main Building Floor: 02 Area: Elec. Rm in Dining Test Performed Result Value Notes Voltage w/ Charger Passed 27.7 Voltage w/o Charger Passed 25.8 Battery % of Charge Passed 100.0 Battery Age Check Passed Control Function(s) Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 5 SITE: Fox Subacute at Mechanicsburg CONTROL PANEL/CENTRAL PROCESSING UNIT Simplex 4100 -8001 Serial # I41504 Building: Main Building Floor: B Area: Electric Rm. by Maintenance Test Performed Result Value Notes Voltage w/ Charger Passed 27.9 Voltage w/o Charger Passed 26.0 Battery % of Charge Passed 100.0 Battery Age Check Passed Control Function(s) Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 6 SITE: Fox Subacute at Mechanicsburg CONTROL PANEL/CENTRAL PROCESSING UNIT Simplex 4009 Serial # I41504 Building: Main Building Floor: B Area: Electric Rm. by Maintenance Test Performed Result Value Notes Voltage w/ Charger Passed 27.2 Voltage w/o Charger Passed 25.7 Battery % of Charge Passed 100.0 Battery Age Check Pied Control Function(s) Pied SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 7 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES SUMMARY TEST RESULTS Dev. Number Number Number Tvpe Description Total Tested Failed Not Tested CSHD Combination Smoke/ Heat Det. 137 137 0 0 DSD Duct Smoke Detector 3 3 0 0 FTHD Fixed Temp Heat Detector 12 12 0 0 PSD Photo Smoke Detector 28 28 0 0 PSSA Pull Station- Single Action 26 26 0 0 DETAIL TEST RESULTS Dev Cust Cust Address/ Service Test Lype Builobw Floor Area Zone Dev# Zone No. Performed Result SHD 1992 Building 01 By Consulting Rm 2 02 104 -102 Tested Cleaned/ Passed ?SSA 1992 Building 01 By Exam #18 02 104 -102 Tested Passed ?SSA 1992 Building 01 By Exam #21 02 104 -102 Tested Passed ?SSA 1992 Building 01 By Exam #6 02 104 -102 Tested Passed ?SSA 1992 Building 01 By Exam #9 02 104 -102 Tested Passed 7SHD 1992 Building 01 By Exam 1 -6 corr 02 104 -102 Tested Cleaned/ Passed SHD 1992 Building 01 By Exam 19 -24 corr 02 104 -102 Tested Cleaned/ Passed - 1992 Building 01 By Exam 7 -12 corr 02 104 -102 Tested Cleaned/ Passed SHD 1992 Building 01 By Exam rm 12 02 104 -102 Tested Cleaned/ Passed _ 1992 Building 01 By Exam rm 16 02 104 -102 Tested Cleaned/ Passed -'SHD 1992 Building 01 By Exam rm 23 02 104 -102 Tested Cleaned/ Passed 'SHD 1992 Building 01 By Exam rm 4 02 104 -102 Tested Cleaned/ Passed _'SHD 1992 Building 01 By Proceedure nn B 02 104 -102 Tested Cleaned/ Passed :SHD 1992 Building 01 By Referal Office 02 104 -102 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 8 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAIL TEST RESULTS Jev Cust Cust Address/ Service Test rvi3e Buddha Floor Area Zone Dev# Zone No. Performed Result 'SHD 1992 Building 01 By Stairs 02 104 -102 Tested Cleaned/ Passed 'SSA 1992 Building 01 By Stairs 02 104 -102 Tested Passed ,SHD 1992 Building 01 By Supply Rm 02 104 -102 Tested Cleaned/ Passed 'SHD 1992 Building 01 Corr by Breakrm 02 104 -102 Tested Cleaned/ Passed 'SHD 1992 Building 01 Corr by Breakrm 02 104 -102 Tested Cleaned/ Passed 'SHD 1992 Building 01 Doctors Office Corr 02 104 -102 Tested Cleaned/ Passed :SHD 1992 Building 01 Front Entrance 02 104 -102 Tested Cleaned/ Passed 'SSA 1992 Building 01 Front entrance 02 104 -102 Tested Passed 'SHD 1992 Building 01 Front Lobby (registration desk) 02 104 -102 Tested Cleaned/ Passed 'SHD 1992 Building 01 Front Lobby (waiting area) 02 104 -102 Tested Cleaned/ Passed 'SHD 1992 Building 01 Front Lobby (waiting area) 02 104 -102 Tested Cleaned/ Passed 'SHD 1992 Building 01 Med records 02 104 -102 Tested Cleaned/ Passed .SHD 1992 Building 01 Storage by 113 02 104 -102 Tested Cleaned/ Passed :SHD 1992 Building 01 Supply rm 02 104 -102 Tested Cleaned/ ;Passed 'SSA 1992 Building 02 By stairs and Board Rm 03 104 -103 Tested Passed 'SHD 1992 Building 02 Elec/ Mech rm 03 104 -103 Tested Cleaned/ Passed :SHD 1992 Building 02 File Rm in Mgmt Office 03 104 -103 Tested Cleaned/ Passed 'SSA 1992 Building 02 Hall at dbl drs to nursing 03 104 -103 Tested Passed 'SD 1992 Building 02 Hall by Board Rm 03 104 -103 Tested Cleaned/ Passed :SHD 1992 Building 02 Hall by Board Rm 03 104 -103 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT :PAGE 9 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAIL TEST RESULTS Dev Cast Cust Address/ Service Test T �e B�� Floor Area Zone Dev# Zone No. Performed Result CSHD 1992 Building 02 Hall by Conf Rm A 03 104 -103 Tested Cleaned/ CSHD 1992 Building 02 Hal] by Conf Rm C Passed 03 104 -103 Tested Cleaned/ Passed CSHD 1992 Building 02 Hall by dbl drs to nursing 03 104 -103 Tested Cleaned/ SHD 1992 Building 02 Hall by Elect Mech Rm Passed 03 104 -103 Tested Cleaned/ 'SSA 1992 Building 02 Hall B health info services Passed SHD 1992 Building 3 104 -103 Tested passed g 02 Hail by Health Info Svcs 03 104 -103 Tested Cleaned/ 'SHD 1992 Building assed g 02 Hal] by Kitchenette 03 104 -103 Tested Cleaned/ Passed SHD 1992 Building 02 Hall by Multi- purpose Rm 03 104 -103 Tested Cleaned/ Passed :SHD 1992 Building 02 Hall by Multi- purpose Rm 03 104 -103 Tested Cleaned! 'SHD 1992 Building 02 Hall by Stairs and Board Rm Passed 03 104 -I03 Tested Cleaned/ 'SHD 1992 Building 02 Health Info Svcs Office P assed 03 104 -103 Tested Cleaned/ 'SHD 1992 Building 02 Office by Elevator Passe 0 3 104 -103 Tested Cleaned/ SHD 1992 Building 02 Old Program coordinator's office Passed 03 104 -103 Tested Cleaned/ SHD 1992 Building 02 Stg / unfinished office in old Osteo Rm 03 Passed 104 -103 Tested Cleaned/ SHD 1992 Building 02 Stg rm by multi -pure rm passed 03 104 -103 Tested Cleaned/ SHD 1992 Building 02 Top of stairs by Board Rm Passed 03 104 -103 Tested Cleaned/ SHD Main Building 01 (Nursing) By 101 07 104 -107 Tested Cleaned/ SHD Main Building 01 (Nursing) By 102 Passed 07 104 -107 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 10 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAIL TEST RESULTS Dev Cust Cust Address/ Service Test Tvpe Buildine Floor Area Zone Dev# Zone No. Performed Result CSHD Main Building 01 (Nursing) By 105 07 104 -107 Tested Cleaned/ Passed PSD Main Building 01 (Nursing) By 107 07 104 -107 Tested Cleaned/ Passed CSHD Main Building 01 (Nursing) By 108 08 104 -108 Tested Cleaned/ Passed PSSA Main Building 01 (Nursing) By 111 08 104 -108 Tested Passed CSHD Main Building 01 (Nursing) By 111 08 104 -108 Tested Cleaned/ Passed - Main Building 01 (Nursing) By 112 08 104 -108 Tested Cleaned/ Passed - Main Building 01 (Nursing) By 114 07 104 -107 Tested Cleaned/ Passed - -SHD Main Building 01 (Nursing) By elect rm 07 104 -107 Tested Cleaned/ Passed 'SSA Main Building 01 (Nursing) Elev lobby 07 104 -107 Tested Passed '-SHD Main Building 01 (Nursing) Elev lobby 07 104 -107 Tested Cleaned/ Passed 'SHD Main Building 01 (Nursing) Med rm 07 104 -107 Tested Cleaned/ Passed 'SHD Main Building 01 (Nursing) Pantry 07 104 -107 Tested Cleaned/ Passed 'SD Main Building 01 (Nursing) Soiled Utility 07 104 -107 Tested Cleaned/ :Passed 'SHD Main Building 01 (Nursing) Storage by Rm 113 07 104 -107 Tested Cleaned/ Passed ;SHD Main Building 01 Copier Rm B 102 -104 Tested Cleaned/ THD Main Building 01 DCA - Bicarb Tank Rm Passed H 103 -108 'Tested Passed Visual Check only -Fixed Temp 'SHD Main Building 01 DCA - By Facility Administrators Office H 103 -108 Tested Cleaned/ 'SSA Main Building 01 DCA - by Medical Records B Passed 103 -107 Tested Passed 'SHD Main Building 01 DCA - by Medical Records H 103 -107 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 11 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAIL TEST RESULTS Dev Cust Cust Address/ Service Test rM Building Floor Area Zone Dev# Zone No. Performed Result �SHD Main Building 01 DCA - By Medical Waste H 103 -108 Tested Cleaned/ Passed - -SHD Main Building 01 DCA - By Social Worker Office H 103 -108 Tested Cleaned/ Passed ,SHD Main Building 01 DCA - By staff lounge H 103 -107 Tested Cleaned/ Passed - -SHD Main Building 01 DCA - Dialysis area H 103 -107 Tested Cleaned/ Passed -SHD Main Building 01 DCA - Dialysis area H 103 -107 Tested Cleaned/ Passed ,SHD Main Building 01 DCA - Dialysis area H 103 -108 Tested Cleaned/ Passed -SHD Main Building 01 DCA - Dialysis area H 103 -108 Tested Cleaned/ Passed - Main Building 01 DCA - Dialysis area H 103 -108 Tested Cleaned/ Passed ,SHD Main Building 01 DCA - Employee Lounge H 103 -107 Tested Cleaned/ Passed 'SSA Main Building 01 DCA - Exit by Medical Waste B 103 -108 Tested Passed - Main Building 01 DCA - Granuflow Mixing Rm H 103 -108 Tested Cleaned/ Passed - Main Building 01 DCA - Medical Waste Rm H 103 -108 Tested Cleaned/ Passed -SHD Main Building 01 DCA - Storage Rm H 103 -108 Tested Cleaned/ Passed -"SHD Main Building 01 DCA - Waiting rm H 103 -107 Tested Cleaned/ Passed 'SSA Main Building 01 DCA - Waiting room B 103 -107 Tested Passed ,SHD Main Building 01 DCA - Water Room H 103 -108 Tested Cleaned/ Passed -'SHD Main Building 01 DCA Corr by Granuflow Mixing Rm H 103 -108 Tested Cleaned/ Passed -'SHD Main Building 01 Director of Nursing Office B 102 -104 Tested Cleaned/ Passed -'SHD Main Building 01 Elevator lobby B 103 -103 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 12 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAE1, TEST RESULTS )ev Cust Cust Address/ Service Test rvoe Building Floor Area Zone Dev# Zone No. Performe Result 'SHD Main Building 01 Former First Place clean utility rm B 102 -102 Tested Cleaned/ Passed 'SHD Main Building 01 Former First Place exam area B 102 -102 Tested Cleaned/ Passed 'SHD Main Building 01 Former First Place exam area B 102 -102 Tested Cleaned/ Passed 'SHD Main Building 01 Former First Place exam area B 102 -102 Tested Cleaned/ Passed 'SSA Main Building 01 Former First Place exam area exit B 102 -105 Tested Passed 'SHD Main Building 01 Former First Place soiled utility rm B 102 -102 Tested Cleaned/ Passed 'SHD Main Building 01 Fox Staff Btreakroom H 103 -107 Tested Cleaned/ Passed :SHD Main Building 01 Hall by Administrator's Office B 102 -104 Tested Cleaned/ Passed :SHD Main Building 01 Hall by former X -Ray B 102 -104 Tested Cleaned/ Passed :SHD Main Building 01 Hall by U.S. Renal Care entrance B 102 -102 Tested Cleaned/ Passed ;SHD Main Building 01 Hallway by Former X -Ray H 103 -103 Tested Cleaned/ Passed 'SHD Main Building 01 Lobby at Ent to Nursing 07 103 -103 Tested Cleaned/ Passed 'SSA Main Building 01 Main Entrance Door 1 Vestibule B 103 -107 Tested Passed 'SSA Main Building 01 Main Entrance Door 6 Vestibule B 103 -107 Tested Passed 'SHD Main Building Of Nurses Office w/ FACP H 102 -102 Tested Cleaned/ Passed 'SHD Main Building 01 Restrm dhru storage by DCA B 102 -104 Tested Cleaned/ Passed 'SHD Main Building 01 Secure File Stg. B 102 -104 Tested Cleaned/ Passed 'SHD Main Building 01 Secure File Stg. B 102 -104 Tested Cleaned/ Passed 'SHD Main Building 01 Storage by DCA B 102 -104 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 13 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAIL TEST RESULTS Dev Cust Cost Address/ Service Test rvoe Building Floor Area Zone Dev# Zone No. Performed Result PSSA Main Building 01 U.S. Renal Care entrance B 102 -105 Tested Passed CSHD Main Building 01 U.S. Renal Care Lobby H 103 -107 Tested Cleaned/ Passed PSSA Main Building 02 At Stairwell by Janitors Closet 11 104 -201 Tested Passed PSD Main Building 02 Clean Utility 10 104 -202 Tested Cleaned/ Passed DSD Main Building 02 Clean Utility AHU Rtn 22 104 -305 Tested Cleaned/ Passed DSD Main Building 02 Corr by Clean Utility AHU N Sply 21 104 -305 Tested Cleaned/ Passed DSD Main Building 02 Corr by Med Rm AHU S Sply 20 104 -305 Tested Cleaned/ Passed ?SD Main Building 02 Dining/ Lounge A/F Elev 10 104 -202 Tested Cleaned/ Passed ?SD Main Building 02 Dining/ Lounge A/F Elev 10 104 -202 Tested Cleaned/ Passed -SHD Main Building 02 Elec Closet in rm A/F elevator 10 104 -202 Tested Cleaned/ Passed -SHD Main Building 02 Elec Closet Near Stairwell & 1992 Bldg. 10 104 -202 Tested Cleaned/ Passed 2SHD Main Building 02 Elev Lobby 15 104 -207 Tested Cleaned/ Passed 'SSA Main Building 02 Elev lobby 10 104 -207 Tested Passed 'SD Main Building 02 Elev Lobby near 1992 Wing 15 104 -207 Tested Cleaned/ Passed 'SD Main Building 02 Hallway North 10 104 -202 Tested Cleaned/ Passed 'SD Main Building 02 Hallway North 10 104 -202 Tested Cleaned/ Passed 'SD Main Building 02 Hallway North by hall to Elev. 10 104 -202 Tested. Cleaned/ Passed 'SD Main Building 02 Hallway North by Med Rm 10 104 -202 Tested Cleaned/ Passed 'SD Main Building 02 Hallway North by restroom 10 104 -202 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGrE 14 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAIL TEST RESULTS Dev Cust Cust Address/ Service Test Type Bmadin Floor Area Zone Dev# Zone No. Performed Result PSD Main Building 02 Hallway North by restroom 10 104 -202 Tested Cleaned/ Passed PSD Main Building 02 Hallway North by Soiled Utility 10 104 -202 Tested Cleaned/ Passed ?SD Main Building 02 Hallway North near Nurse Station 10 104 -202 Tested Cleaned/ Passed PSD Main Building 02 Hallway South 11 104 -203 Tested Cleaned/ Passed PSD Main Building 02 Hallway South near Janitor Closet 11 104 -203 Tested Cleaned/ Passed 'SD Main Building 02 Hallway South near Shower Rm 11 104 -203 Tested Cleaned/ Passed 'SD Main Building 02 Janitor Closet 11 104 -203 Tested Cleaned/ Passed 'SD Main Building 02 Lounge next to Elev. 10 104 -202 Tested Cleaned/ Passed 'SD Main Building 02 Med Rm 10 104 -202 Tested Cleaned/ Passed -SHD Main Building 02 Near Elev Lobby 10 104 -202 Tested Cleaned/ Passed 'SD Main Building 02 Shower Rm 11 104 -203 Tested Cleaned/ Passed 'SD Main Building 02 Soiled Utility 10 104 -202 Tested Cleaned/ Passed 'SD Main Building 02 Storage Rm near Nurse Station 10 104 -202 Tested Cleaned/ Passed 'SHD Main Building 02 Top of Stairs by Elevator 10 104 -202 Tested Cleaned/ Psed 'SHD Main Building 02 Top of Stairs by Janitors Closet 11 104 -201 Tested Cleaned/ Passed 'SSA Main Building B Bottom of stairs by mammography 04 104 -104 Tested Passed THD Main Building B By large storage room H 103 -102 Tested Passed Visual Check only -Fixed Temp SSA Main Building B By Old Security Office B 103 -102 Tested Passed 'SHD Main Building B Clean Linen by Old X -Ray 04 104 -104 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 15 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAEL TEST RESULTS Dev Cust Cust Address/ Service Test Type Building Floor Area Zone Dev# Zone No. Performed ResWt CSHD Main Building B Corr By Dining Rm 04 104 -104 Tested Cleaned/ Passed - -SHD Main Building B Corr by elev / stairs 04 104 -104 Tested Cleaned/ Passed CSHD Main Building B Corr by Elev Machine Rm B 103 -102 Tested Cleaned/ Passed PSD Main Building B Corr by Former Mammography 04 104 -104 Tested Cleaned/ Passed :'SHD Main Building B Corr By Former PT B 103 -102 Tested Cleaned/ Passed SHD Main Building B Corr By Former PT H 103 -102 Tested Cleaned/ Passed 'SHD Main Building B Corr By Former PT H 103 -102 Tested Cleaned/ Passed 'SHD Main Building B Corr by kitchen 04 104 -104 Tested Cleaned/ Passed 'SHD Main Building B Corr By old Security Office H 103 -102 Tested Cleaned/ Passed 'SHD Main Building B Corr By old Security Office H 103 -102 Tested Cleaned/ Passed 'SSA Main Building B Corr by oxygen storage B 103 -102 Tested Passed 'SHD Main Building B Corr by oxygen storage H 103 -102 Tested Cleaned/ Passed 'SHD Main Building B Corr by oxygen storage H 103 -102 Tested Cleaned/ Passed 'SHD Main Building B Corr By Smoke Drs to 1958 Bldg. B 103 -102 Tested Cleaned/ ' Passed SHD Main Building B Corr By Store Room H 103 -102 Tested Cleaned/ Passed 'SHD Main Building B Elect rm by maint shop (FACP Rm) 04 104 -104 Tested Cleaned/ :Passed 'SHD Main Building B Elev lobby 04 104 -104 Tested Cleaned/ Passed 'SSA Main Building B Elevator lobby 04 104 -104 Tested Passed THD Main Building B Elevator machine room H 103 -102 Tested Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 16 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAIL TEST RESULTS Dev Cust Cust Address/ Service Test roue Building Floor Area Zone Dev# Zone No. Performed Result Pl'HD Main Building B Elevator machine room H 103 -102 ...continued... Visual Check only -Fixed Temp 'SHD Main Building B Employee Break Area H 102 -103 Tested Cleaned/ Passed 'SHD Main Building B Employee Break Area H 102 -103 Tested Cleaned/ Passed 'SHD Main Building B Former Mammo by Stairs 04 104 -104 Tested Cleaned/ Passed 'SD Main Building B Former Mammo stg rm 04 104 -104 Tested Cleaned/ Passed 'SHD Main Building B Former Mammo waiting rm 04 104 -104 Tested Cleaned/ Passed 'SHD Main Building B Former Mammo workrm 1 04 104 -104 Tested Cleaned/ Passed 'SHD Main Building B Former Occupational Therapy H 102 -103 Tested Cleaned/ Passed 'SHD Main Building B Former Occupational Therapy H 102 -103 Tested Cleaned/ Passed :SHD Main Building B Former Occupational Therapy H 102 -103 Tested Cleaned/ Passed 'SHD Main Building B Former Occupational Therapy H 102 -103 Tested Cleaned/ Passed ,SHD Main Building B Former Occupational Therapy H 102 -103 Tested Cleaned/ Passed 'SHD Main Building B Former Occupational Therapy H 102 -103 Tested Cleaned/ Passed 'SSA Main Building B Former Occupational Therapy Exit B 102 -103 Tested Passed 'SHD Main Building B Former PT Washroom B 103 -102 Tested Cleaned/ Passed THD Main Building B Garage H 103 -102 Tested Passed Visual Check only -Fixed Temp 7HD Main Building B Garage H 103 -102 Tested Passed Visual Check only -Fixed Temp 7 rHD Main Building B Garage H 103 -102 Tested Passed Visual Check only -Fixed Temp 'SD Main Building B Housekeeping Storage 04 104 -104 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 17 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAIL TEST RESULTS Dev Cust Cust Address/ Service Test I'vne Buildine Floor Area Zone Dev# Zone No. Performed Result 2SHD Main Building B Infectious Waste Rm 05 104 -105 Tested Cleaned/ Passed L'SHD Main Building B Janitor's Closet by old PT B 103 -102 Tested Cleaned/ Passed FTHD Main Building B Kitchen 05 104 -105 Tested Passed Visual Check only -Fixed Temp FTHD Main Building B Kitchen 05 104 -105 Tested Passed Visual Check only -Fixed Temp 7SHD Main Building B Kitchen dry stg 05 104 -105 Tested Cleaned/ Passed 7SHD Main Building B Large stg rm H 103 -101 Tested Cleaned/ Passed - _SHD Main Building B Large stg rm H 103 -101 Tested Cleaned/ Passed -SHD Main Building B Large stg rm H 103 -101 Tested Cleaned/ Passed _ Main Building B Large stg rm H 103 -101 Tested Cleaned/ Passed `THD Main Building B Laundry H 103 -102 Tested Passed Visual Check only -Fixed Temp AHD Main Building B Maintenance room 01 104 -101 Tested Passed Visual Check only -Fixed Temp 'SHD Main Building B Mech rm by security office B 103 -102 Tested Cleaned/ Passed -SHD Main Building B Mech rm by security office B 103 -102 Tested Cleaned/ Passed 'SSA Main Building B Mechanical room by kitchen 04 104 -105 Tested Passed 1'HD Main Building B Mechanical room by kitchen 05 104 -105 Tested Passed Visual Check only -Fixed Temp 7HD Main Building B Mechanical room by kitchen 05 104 -105 Tested Passed Visual Check only -Fixed Temp "SHD Main Building B Office #1 by Elev H 103 -102 Tested Cleaned/ Passed 'SD Main Building B Office #2 by Elev H 103 -102 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 18 SITE: Fox Subacute at Mechanicsburg ALARM INITIATING DEVICES DETAIL TEST RES Tr TS Dev Typ Buil Cust Cust Address/ Service Test ..YJ� Floor Area Zone Dev# Zone No. Performed Result CSHD Main Building B Old file stg rm by security B 103 -102 Tested Cleaned/ 2SHD Main Building B Old Security Office B Passed 103 -102 Tested Cleaned/ - -SHD Main Building B Old X -Ray rm Passed y 04 104 -104 Tested Cleaned/ - Main Building P Elev lobby assed y H 104 -201 Tested Cleaned/ Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 19 SITE: Fox Subacute at Mechanicsburg ALARM INDICATING DEVICES SUMMARY TEST RESULTS Dev. Number Number Number Type Description Total Tested Failed Not Tested ANNC Annunciator 2 2 0 0 CRT Display Terminal 1 1 0 0 DETAIL TEST RESULTS )ev Cust Cust Address/ Service Test -fie B Floor Area Zone Dev# Zone No. Performed Result �NNC Main Building 01 Nurses station Tested Passed ►NNC Main Building 02 Nurses station Tested Passed 'RT Main Building B Former Security office Tested Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 20 SITE: Fox Subacute at Mechanicsburg SENSITIVITY TESTING SUMMARY TEST RESULTS Dev. Cust Cust Address/ Prior Current Test Type Floor Area Zone Dev# Zone No. Mfg. Range Test Test Result Building: 1992 Building CSHD 01 By Consulting Rm 2 02 104 -102 N/A 2.5 Passed CSHD 01 By Exam 1 -6 corr 02 104 -102 N/A 2.5 Passed CSHD 01 By Exam 19 -24 corr 02 104 -102 N/A 2.5 Passed CSHD 01 By Exam 7 -12 corr 02 104 -102 N/A 2.5 Passed CSHD 01 By Exam rm 12 02 104 -102 N/A 2.5 Passed CSHD 01 By Exam rm 16 02 104 -102 N/A 2.5 Passed CSHD 01 By Exam rm 23 02 104 -102 N/A 2.5 Passed CSHD 01 By Exam rm 4 02 104 -102 N/A 2.5 Passed CSHD 01 By Proceedure rm B 02 104 -102 N/A 2.5 Passed CSHD 01 By Referal Office 02 104 -102 N/A 2.5 Passed CSHD 01 By Stairs 02 104 -102 N/A 2.5 Passed CSHD 01 By Supply Rm 02 104 -102 N/A 2.5 Passed CSHD 01 Corr by Breakrm 02 104 -102 N/A 2.5 Passed CSHD 01 Corr by Breakrm 02 104 -102 N/A 2.5 Passed CSHD 01 Doctors Office Corr 02 104 -102 N/A 2.5 Passed CSHD 01 Front Entrance 02 104 -102 N/A 2.5 Passed CSHD 01 Front Lobby (registration desk) 02 104 -102 N/A 2.5 Passed CSHD 01 Front Lobby (waiting area) 02 104 -102 N/A 2.5 Passed CSHD 01 Front Lobby (waiting area) 02 104 402 N/A 2.5 Passed CSHD 01 Med records 02 104 -102 N/A 2.5 Passed CSHD 01 Storage by 113 02 104 -102 N/A 2.5 Passed CSHD 01 Supply rm 02 104 -102 N/A 2.5 Passed CSHD 02 Elec/ Mech rm 03 104 -103 N/A 2.5 Passed CSHD 02 File Rm in Mgmt Office 03 104 -103 N/A 2.5 Passed CSHD 02 Hall by Board Rm 03 104 -103 N/A 2.5 Passed PSD 02 Hall by Board Rm 03 104 -103 N/A 2.5 Passed CSHD 02 Hall by Conf Rm A 03 104 -103 N/A 2.5 Passed CSHD 02 Hall by Conf Rm C 03 104 -103 N/A 2.5 Passed CSHD 02 Hall by dbl drs to nursing 03 104 -103 N/A 2.5 Passed CSHD 02 Hall by Elec/ Mech Rm 03 104 -103 N/A 2.5 Passed CSHD 02 Hall by Health Info Svcs 03 104 -103 N/A 2.5 Passed CSHD 02 Hall by Kitchenette 03 104 -103 N/A 2.5 Passed CSHD 02 Hall by Multi- purpose Rm 03 104 -103 N/A 2.5 Passed CSHD 02 Hall by Multi- purpose Rm 03 104 -103 N/A 2.5 :Passed CSHD 02 Hall by Stairs and Board Rm 03 104 -103 N/A 2.5 ;Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 21 SITE: Fox Subacute at Mechanicsburg SENSITIVITY TESTING SUMMARY TEST RESULTS Dev. Cust Cust Address/ Prior Current Test Tyne Floor Area Zone Dev# Zone No. Mfg. Rance Test Test Result CSHD 02 Health Info Svcs Office 03 104 -103 N/A 2.5 Passed CSHD 02 Office by Elevator 03 104 -103 N/A 2.5 Passed CSHD 02 Old Program coordinator's office 03 104 -103 N/A 2.5 Passed CSHD 02 Stg / unfinished office in old Osteo Rm 03 104 -103 N/A 2.5 Passed CSHD 02 Stg rm by multi -purp rm 03 104 -103 N/A 2.5 Passed CSHD 02 Top of stairs by Board Rm 03 104 -103 N/A 2.5 Passed Building: Main Building CSHD 01 (Nursing) By 101 07 104 -107 N/A 2.5 Passed CSHD 01 (Nursing) By 102 07 104 -107 N/A 2.5 Passed CSHD 01 (Nursing) By 105 07 104 -107 N/A 2.5 Passed PSD 01 (Nursing) By 107 07 104 -107 N/A 2.5 Passed CSHD 01 (Nursing) By 108 08 104 -108 0.0 2.5 Passed CSHD 01 (Nursing) By 11 l 08 104 -108 N/A 2.5 Passed CSHD 01 (Nursing) By 112 08 104 -108 N/A 2.5 Passed CSHD 01 (Nursing) By 114 07 104 -107 N/A 2.5 Passed CSHD 01 (Nursing) By elect rm 07 104 -107 N/A 2.5 Passed CSHD 01 (Nursing) Elev lobby 07 104 -I07 N/A 2.5 Passed CSHD 01 (Nursing) Med rm 07 104 -107 N/A 2.5 Passed CSHD 01 (Nursing) Pantry 07 104 -107 N/A 2.5 Passed PSD 01 (Nursing) Soiled Utility 07 104 -107 N/A 2.5 Passed CSHD 01 (Nursing) Storage by Rm 113 07 104 -107 N/A 2.5 Passed CSHD 01 Copier Rm B 102 -104 N/A 2.5 Passed CSHD 01 DCA - By Facility Administrators Office H 103 -108 N/A 2.5 Passed CSHD 01 DCA - by Medical Records H 103 -107 N/A 2.5 Passed CSHD 01 DCA - By Medical Waste H 103 -108 N/A 2.5 Passed CSHD 01 DCA - By Social Worker Office H 103 -108 N/A 2.5 Passed CSHD 01 DCA - By staff lounge H 103 -107 N/A 2.5 Passed CSHD 01 DCA - Dialysis area H 103 -108 N/A 2.5 Passed CSHD 01 DCA - Dialysis area H 103 -108 N/A 2.5 Passed CSHD 01 DCA - Dialysis area H 103 -108 N/A 2.5 Passed CSHD 01 DCA - Dialysis area H 103 -107 N/A 2.5 Passed CSHD 01 DCA - Dialysis area H 103 -107 N/A 2.5 Passed CSHD 01 DCA - Employee Lounge H 103 -107 N/A 2.5 Passed CSHD 01 DCA - Granuflow Mixing Rm H 103 -108 N/A 2.5 Passed CSHD 01 DCA - Medical Waste Rm H 103 -108 N/A 2.5 Passed CSHD 01 DCA - Storage Rm H 103 -108 N/A 2.5 Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 22 SITE: Fox Subacute at Mechanicsburg SENSITIVITY TESTING SUMMARY TEST RESULTS Dev. Cust Cust Address/ Prior Current. Test Tvoe Floor Area Zone Dev# Zone No. Mfg. Range Test Test Result CSHD 01 DCA - Waiting rm H 103 -107 N/A 2.5 Passed CSHD 01 DCA - Water Room H 103 -108 N/A 2.5 Passed CSHD 01 DCA Cotr by Granuflow Mixing Rm H 103 -108 NIA 2.5 Passed CSHD 01 Director of Nursing Office B 102 -104 N/A 2.5 Passed CSHD 01 Elevator lobby B 103 -103 N/A 2.5 Passed CSHD 01 Former First Place clean utility rm B 102 -102 N/A 2.5 Passed CSHD 01 Former First Place exam area B 102 -102 N/A 2.5 Passed CSHD 01 Former First Place exam area B 102 -102 N/A 2.5 Passed CSHD 01 Former First Place exam area B 102 -102 N/A 2.5 Passed CSHD 01 Former First Place soiled utility rm B 102 -102 N/A 2.5 Passed CSHD 01 Fox Staff Btreakroom H 103 -107 N/A 2.5 Passed CSHD 01 Hall by Administrators Office B 102 -104 N/A 2.5 Passed CSHD 01 Hall by former X -Ray B 102 -104 N/A 2.5 Passed CSHD 01 Hall by U.S. Renal Care entrance B 102 -102 N/A 2.5 Passed CSHD 01 Hallway by Former X -Ray H 103 -103 N/A 2.5 Passed CSHD 01 Lobby at Ent to Nursing 07 103 -103 N/A 2.5 Passed CSHD 01 Nurses Office w/ FACP H 102 -102 N/A 2.5 Passed CSHD 01 Restrm thru storage by DCA B 102 -104 N/A 2.5 Passed CSHD 01 Secure File Stg. B 102 -104 N/A 2.5 Passed CSHD 01 Secure File Stg. B 102 -104 N/A 2.5 Passed CSHD 01 Storage by DCA B 102 -104 N/A 2.5 Passed CSHD 01 U.S. Renal Care Lobby H 103 -107 N/A 2.5 Passed PSD 02 Clean Utility 10 104 -202 0.0 2.5 Passed PSD 02 Dining/ Lounge A/F Elev 10 104 -202 N/A 2.5 Passed PSD 02 Dining/ Lounge A/F Elev 10 104 -202 N/A 2.5 Passed CSHD 02 Elec Closet in rm A/F elevator 10 104 -202 N/A 2.5 Passed CSHD 02 Elec Closet Near Stairwell & 1992 Bldg. 10 104 -202 N/A 2.5 Passed CSHD 02 Elev Lobby 15 104 -207 N/A 2.5 Passed PSD 02 Elev Lobby near 1992 Wing 15 104 -207 N/A 2.5 Passed PSD 02 Hallway North 10 104 -202 N/A 2.5 Passed PSD 02 Hallway North 10 104 -202 N/A 2.5 Passed PSD 02 Hallway North by hall to Elev. 10 104 -202 N/A 2.5 Passed PSD 02 Hallway North by Med Rm 10 104 -202 N/A 2.5 Passed PSD 02 Hallway Notch by restroom 10 104 -202 N/A 2.5 Passed PSD 02 Hallway North by restroom 10 104 -202 N/A 2.5 Passed PSD 02 Hallway North by Soiled Utility 10 104 -202 N/A 2.5 Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 23 SITE: Fox Subacute at Mechanicsburg SENSITIVITY TESTING SUMMARY TEST RESULTS Dev. Cust Cust Address/ Prior Current: Test Tvoe Floor Area Zone Dev# Zone No. Wk. Ranee Test Test Result PSD 02 Hallway North near Nurse Station 10 104 -202 N/A 2.5 Passed PSD 02 Hallway South 11 104 -203 N/A 2.5 Passed PSD 02 Hallway South near Janitor Closet 11 104 -203 N/A 2.5 Passed PSD 02 Hallway South near Shower Rm 11 104 -203 N/A 2.5 Passed PSD 02 Janitor Closet 11 104 -203 N/A 2.5 Passed PSD 02 Lounge next to Elev. 10 104 -202 N/A 2.5 Passed PSD 02 Med Rm 10 104 -202 NIA 2.5 Passed CSHD 02 Near Elev Lobby 10 104 -202 N/A 2.5 Passed PSD 02 Shower Rm 11 104 -203 N/A 2.5 Passed PSD 02 Soiled Utility 10 104 -202 N/A 2.5 Passed PSD 02 Storage Rm near Nurse Station 10 104 -202 N/A 2.5 Passed CSHD 02 Top of Stairs by Elevator 10 104 -202 N/A 2.5 Passed CSHD 02 Top of Stairs by Janitors Closet 11 104 -201 N/A 2.5 Passed CSHD B Clean Linen by Old X -Ray 04 104 -104 N/A 2.5 Passed CSHD B Corr By Dining Rm 04 104 -104 N/A 2.5 Passed CSHD B Corr by elev / stairs 04 104 -104 N/A 2.5 Passed CSHD B Corr by Elev Machine Rm B 103 -102 N/A 2.5 Passed PSD B Corr by Former Mammography 04 104 -104 N/A 2.5 Passed CSHD B Corr By Former PT B 103 -102 N/A 2.5 Passed CSHD B Corr By Former PT H 103 -102 N/A 2.5 Passed CSHD B Corr By Former PT H 103 -102 N/A 2.5 Passed CSHD B Corr by kitchen 04 104 -104 N/A 2.5 Passed CSHD B Corr By old Security Office H 103 -102 N/A 15 Passed CSHD B Corr By old Security Office H 103 -102 N/A 2.5 Passed CSHD B Corr by oxygen storage H 103 -102 N/A 2.5 Passed CSHD B Corr by oxygen storage H 103 -102 N/A 2.5 Passed CSHD B Corr By Smoke Drs to 1958 Bldg. B 103 -102 N/A 2.5 Passed CSHD B Corr By Store Room H 103 -102 N/A 2.5 Passed CSHD B Elect rm by maint shop (FACP Rm) 04 104 -104 NIA 2.5 Passed CSHD B Elev lobby 04 104 -104 N/A 2.5 Passed CSHD B Employee Break Area H 102 -103 N/A 2.5 Passed CSHD B Employee Break Area H 102 -103 N/A 2-5 Passed CSHD B Former Mammo by Stairs 04 104 -104 N/A 2.5 Passed PSD B Former Mammo stg rm 04 104 -104 NIA 15 Passed CSHD B Former Mammo waiting rm 04 I04 -104 N/A 2.5 Passed CSHD B Former Mammo workrm 1 04 104 -104 N/A 2.5 Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 24 SITE: Fox Subacute at Mechanicsburg SENSITIVITY TESTING SUMMARY TEST RESULTS Dev. Cust Cust Address/ Prior Current. Test Tyne Floor Area Zone Dev# Zone No. Mfg. Rance Test Test Result CSHD B Former Occupational Therapy H IO2 -103 N/A 2.5 Passed CSHD B Former Occupational Therapy H 102 -103 N/A 2.5 Passed CSHD B Former Occupational Therapy H 102 -103 N/A 2.5 Passed CSHD B Former Occupational Therapy H 102 -103 N/A 2.5 Passed CSHD B Former Occupational Therapy H 102 -103 N/A 2.5 Passed CSHD B Former Occupational Therapy H 102 -103 N/A 2.5 Passed CSHD B Former PT Washroom B 103 -102 N/A 2.5 Passed PSD B Housekeeping Storage 04 104 -104 N/A 2.5 Passed CSHD B Infectious Waste Rm 05 104 -105 N/A 2.5 Passed CSHD B Janitor's Closet by old PT B 103 -102 N/A 2.5 Passed CSHD B Kitchen dry stg 05 104 -105 N/A 2.5 Passed CSHD B Large stg rm H 103 -101 N/A 25 Passed CSHD B Large stg rm H 103 -101 N/A 2.5 Passed CSHD B Large stg rm H 103 -101 N/A 2.5 Passed CSHD B Large stg rm H 103 -101 N/A 2.5 Passed CSHD B Mech rm by security office B 103 -102 N/A 15 Passed CSHD B Mech rm by security office B 103 -102 N/A 2.5 Passed CSHD B Office #1 by Elev H 103 -102 N/A 2.5 Passed PSD B Office #2 by Elev H 103 -102 0.0 2.5 Passed CSHD B Old file stg rm by security B 103 -102 N/A 2.5 Passed CSHD B Old Security Office B 103 -102 N/A 2.5 Passed CSHD B Old X -Ray rm 04 104 -104 N/A 2.5 Passed CSHD P Elev lobby H 104 -201 N/A 2.5 Passed SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 25 SITE: Fox Subacute at Mechanicsburg INSPECTION DEFICIENCIES SUMMARY THERE WERE NO DEFICIENCIES NOTED DURING THIS INSPECTION SimplexGrinnell FIRE ALARM INSPECTION REPORT PAGE 26 SITE: Fox Subacute at Mechanicsburg Customer Date Customer (Print) Date Matt Smith Date Joe Bair Date IF YOU HAVE ANY QUESTIONS REGARDING THIS REPORT, PLEASE CONTACT Ken Bogue Branch Service Manager Phone: (717) 610 -8111 Fax: (717) 610 -8101 Address: 4700 Westport Dr. Suite 1800 Mechanicsburg, PA, 17055 80650890.A08 FIREALARN INSPECT /ON REPORT ConNrmation 8 Signature Page Thursday, September 06, 2012 Single Site / Single Report Method of report delivery: Hardcopy Fox Subacute (Legacy # 80650890) Address: 120 S. Filbert St. - Mechanicsburg - PA - 17055 Contact info: Ph: 717 -4S8 -0932 - Fax. 717 -458 -0946 - E -mail: bhoia0foxsubacute.com Fire Alarm audio /visual signals were sounded during this inspection 01VOW2012 o pff� C-wh Initials Deficiencies / Recommendations No deficiencies were found No recommendations were noted during this inspection NOTE: No additional notes SimplexGrinnell Representativels) Authorized Customer / Representative 0W051 load Inv 1 A. S Matt Smith (inspector) Bill Haig i M06/2012 03:152 rn InQa2 Authorized Deficiency Contact Joe Bair (Inspector) Name: Same _ Phone: Same PLEASE DIRECT ANY QUESTIONS OR CONCERNS REGARDING THIS REPORT TO: IF YOU REQUIRE ASSISTANCE REGARDING DEFICIENCIES OR RECOMMENDATIONS NOTED IN THIS REPORT, PLEASE CONTACT: Inter -office t Use Only 23625580 SR #'s SG #528 District - 4700 Westport Dr - Suite 1800 - www.simplexgrinnell.com Mechanicsburg, PA 17055 - Phone (717) 610 -8100 - Fax ©xaq�sr adaamrpN[lTaarOtMfa (717) 610 -8101- Service (717) 610 -8111 D -U -N -S 0 9- 4 73 8007 FED. ID 58- 2608861 S/Ill p/ex6Anne//BESAFE. 75412529 07 -26 -12 ATyco International Company w i District 528 18835259 9700 West Dr MECHANICSBURG, PA 17055 -0000 717 - 610 -8100 P n+ -�� 528- 01945228 COD Fox Subacute at Mechanicsburg 528 - 01945228 120 S Filbert St Fox Subacute at Mechanicsburg MECHANICSBURG PA 17055 -0000 120 S Filbert St MECHANICSBURG PA 17055 -0000 Haig, Bill M OM " Fox Subacut at Mechanicsburg -120 S Filbert St- 01945228 O1- JUL -12 30- JUN -13 This is your annual Fire alarm invoice for Fox Subacute at Mechanicsburg located at 120 Filbert St, (Mechanicsburg,. PA. 17055 Total Contract Amount - $4,264.00 Amount Of Current Invoice - $4,264.00 Sales Tax - $0.00 Total Amount Included - $4,264.00 Payment Received - $0.00 Total Amount Due D $4, 264.00 REMITTANCE COPY SEI>s�/7OR0� BE SAFE TOTAL AMOUNT DUE M ' «w � 4,264.00 erla. To Fox Subacute at Mechanicsburg 1NV010E NUMBER 75412529 528- 01945228 SHIP TO Fox Subacute at Mechanicsburg INVOICE DATE 07 -26 -12 528 - 01945228 CUSTOMER P.O. RSPD'T TO SimplexGrinnell Dept_ CH 10320 Palatine IL 60055 -0320 6000426400775412529 32 1 -cG -Coot i -M99^ EXHIBIT SinIPIONOWNne// BE SAFE. Di # 528 s. x A Tyco International Company 4700 Westport Dr MECHANICSBURG, PA 17055 -0000 15412529 717 - 610 -8100 �. 07 26 -12 INVOICE CONTRACT DETAIL Fire Alarm Test 01-JUL-12 30- ,TUN -13 120 S Filbert St, SYSTEM- FA -SMPLX ¢� Inspect 1 SIMPLEX PROGRAMMABLE $4,264.00 ME CHANICSBURG, PA 4100/4020 FIRE ALARM SYSTEM j SYSTEM- FA -SMPLX 1 SIMPLEX 4100/4020 FIRE 4100 /4020 ALARM SYSTEM FA -MAIN PANEL 2 Main Fire Alarm Panel FA- ANNUNCIATOR 1 Annunciator FA -SMOKE DET ADDR 6 Smoke Sensor ' Addressable FA -SMOKE SENS W /HEAT 180 Smoke Sensor with Heat I FA - Addressable HEAT DETECTOR 10 Heat Detector Restorable FA -PULL' 25 Pull Station j i I I j i j I j 328 SL- Contract -M99% D -U -N -S 09- 4738007 FED. ID 58- 2608861 '-- +..._ r ^•ter . .�� ''+; P- (�1�R,t�ir` 5 //sp1eJr6JfnJ1e1 1 BE SAFE. 68094326 08 -21 -12 ` ATyco International Company - District # 528 4700 Westport Dr 24035312 `" MECxAWlcsBVRC,PA voss -000a 08- 20 -12� 717 -610 -9100 Billing Questions, Contact = Sherry Ann Calamia 528- 01945228 COD Fox Subacute at Mechanicsburg 120 S Filbert St ' • 528- 01945228 MECHANICSBURG PA 17055 -0000 Fox Subacute at Mechanicsburg 120 S Filbert St MECHANICSBURG PA 17055 -0000 "Let us know how we are doing" ww.simplezgrinaell_com Bill Haig • • • 717 -448 -9718 Fixed Price Service Request scope of work for service performed on your Simplex 4100/4020 Fire Alarm system is not covered b Labor y your service agreement —_ $0. 00 Description of work Material t$1, 86. 02 Billable service call tech replaced a nac panel board. Task # 34315983 8/21/12 If you have any questions, please feel free to Other $ 0. call me at 240- 313 -7021 Brenda Williams Invoice Amount $1,286.02 Taxes $77.16 Total Invoice Amount $1,363.18 Payment Received $0.00 Total Amount Due D $1, 363.18 P isn®N VESAFF. REMITTANCE COPY ATyco lnMnan j Company TOTAL AMOUNT DUE SILL To $1, 363.16 Fox VO Subacute at Mechanics INICE NUMBER 68094326 528 - 01945228 SXzP To Fox Subacute at Mechanicsburg INVOICE DATE 528 - 01945228 08 -21 -12 CUSTOMER P.O. IT SimplexGrinnell Dept. CH 10320 Palatine IL 60055 -0320 60 00136318468094326 Cr 1 Pay by 144 SL- Service -M997 V. VERIFICATION The undersigned does hereby verify subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities, and under penalty of perjury, that he��is , — 41, ' - 1".4 of 6 /2'�,�e'/ / /P l aintiff herein, that he /she is duly authorized to make this Verification and that the facts set forth in the foregoing COMPLAINT are true and correct to the best of his/her knowledge, information and belief. t a (Sign in Blue Ink) MARIO ALEJANDRO'AYAPAN a,A Notary Public COMMONWEALTH 0= r:!aSSACHUSETTS y My Commission Expires November 22, 2013 5 C0077246 SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny RAnderson n - FILED-OF ICS-, Lit' t' THE PRCT3CCr�;- <, �Q qsr of IrrMbr '�A Jody S Smith 1013 MAR 26 AM 9: 34 Chief Deputy Richard W Stewart `" CUMBERLAND COUNTY Solicitor OFFICE OF THE SKERIFC PENNSYLVANIA SimplexGrinnell LP Case Number vS. 2013-1389 Fox Subacute at Mechanicsburg, LLC SHERIFF'S RETURN OF SERVICE 03/21/2013 12:18 PM- Deputy Wiliam Cline, being duly sworn according to law, served the requested Complaint& Notice by handing a true copy to a person representing themselves to be Virona Rowe, Front Desk,who accepted as"Adult Person in Charge"for Fox Subacute at Mechanicsburg, L C at 120 S. Fibert Street, Mechanicsburg Borough, Mechanicsburg, PA 17055. WILLIAM CLINE, DEPUTY SHERIFF COST: $38.00 SO ANSWERS, March 25, 2013 RbNtrY R ANDERSON, SHERIFF (c}CounlySuite Sheriff,Teleosoft.Inc. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION c:. a SIMPLEXGRINELL, LP. NO. 13-1389 CIVIL TERM Plaintiff rnm V. rQ we r'j � FOX SUBACUTE AT MECHANICSBURG, LLC ATTY ID NO. =:c) CDC,) I Defendant .� co ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly enter the appearance of the undersigned for the Defendant in the above captioned matter. OfEP?16DMNo.23201 URRA�., Q. . ttorne 120 S. Filbert Street Mechanicsburg, PA 17055 (717) 458-0931 (717) 458-0702 fax IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINELL, LP. NO. 13-1389 CIVIL TERM Plaintiff ' c w V. rn -0 rn FOX SUBACUTE AT MECHANICSBURG, LLC ATTY ID NO. 31699 tom- Ni Defendant Z o .s� Q DEFENDANT'S ANSWER TO PLAINTIFF'S COMPLAINT 4 ° COMES NOW, the Defendant, by and through its undersigned counsel, and respectfully answers the Plaintiffs complaint as follows: 1. Admitted. 2. Admitted. 3. Denied as stated. There is no agreement attached to the Complaint regarding any professional service performed on September 6, 2012. The form attached to the complaint and marked as "A concerns August 21, 2012. Strict proof of this averment is demanded. 4. Admitted in part and denied in part. It is admitted that Plaintiff performed services on Defendant's property on the dates set forth on the invoices attached to Plaintiff's complaint. It is denied that Defendant requested the specific services performed and billed by Plaintiff.. Strict proof of this averment is demanded. 5. Denied. It is denied that Defendant accepted the services set forth on the invoice.. 6. Denied. It is specifically denied that that the prices charged by Plaintiff were fair and reasonable and the market prices that prevailed at the time the services were rendered. To the contrary, Defendant believes and therefore avers that the prices charged by Plaintiff were exorbitant and far in excess of the reasonable value for such service. Strict proof of this averment is demanded. 7. Denied. Defendant denies that it ever agreed to pay Plaintiff the prices set forth on the invoices. Strict proof of this averment is demanded. 8. Denied. Defendant denies that it is indebted to Plaintiff in the amount set forth on the invoices attached to the Complaint. It is denied that Defendant owes any interest to Plaintiff. Strict proof of this averment is demanded. r' 9. Denied. Defendant denies that there is any agreement between Plaintiff and Defendant, written, oral or implied, regarding the payment of interest. Strict proof of this averment is demanded. 10. Denied. Defendant denies that there is any agreement between Plaintiff and Defendant, written, oral or implied, regarding collection costs or attorney's fees. Strict proof of this averment is demanded. 11. Denied. Defendant denies that it owes Plaintiff any collection costs or attorney's fees whatsoever. Strict proof of this averment is demanded. WHEREFORE, Defendant requests that this Honorable Court dismiss the Complaint against it. sp ctfully subm'tte ep sq. 120 . Filb Street chanicsburg, PA 17055 (717) 458-0931 (717) 458-0702 fax ds`c • VERIFICATION WALTER B. DUNSMORE, the undersigned,does hereby verify that he is the Chief Financial Officer of the Defendant named herein, that he is authorized to make this verification on its behalf and that the facts set forth in the foregoing Answer to Plaintiff's Complaint are true and correct to the best of his knowledge, information and belief. I understand that any false statements made in the Answer are subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. J WALTER B. DUNSMORE IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINNELL, LP, C= Plaintiff, . 0ti' vs. Civil Action No. 13-1389 yam, -0 = C) FOX SUBACUTE AT r=` MECHANICSBURG, LLC, `� w Defendant. PETITION FOR APPOINTMENT OF ARBITRATORS PURSUANT TO C.C.R.P. 1302-2 FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: SHAWN P. MCCLURE, ESQUIRE PA ID #205951 JENNIFER L. TIS, ESQUIRE PA ID #203751 RAYMOND P. WENDOLOWSKI, JR., ESQUIRE PA ID#311415 Bernstein-Burkley, P.C. Firm#718 707 Grant Street Suite 2200 - Gulf Tower Pittsburgh, PA 15219 412-456-8100 BERNSTEIN FILE NO. C0077246 I� �9d��� IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINNELL, LP, Plaintiff, VS. Civil Action No. 13-1389 FOX SUBACUTE AT MECHANICSBURG, LLC, Defendant. PETITION FOR APPOINTMENT OF ARBITRATORS PURSUANT TO C.C.R.P. 1302-2 TO: PROTHONOTARY OF CUMBERLAND COUNTY Shawn P. McClure, counsel for the Plaintiff, SimplexGrinnell, L.P., in the above action, respectfully represents that: 1. The above-captioned action is at issue. 2. The claim of the Plaintiff in the action is $7,669.85. 3. The following attorneys are interest in the case as counsel or otherwise disqualified to sit as arbitrators: Joseph F. Murray WHEREFORE,your petitioner prays your Honorable Court to appoint three(3) arbitrators to whom the case shall be submitted. BERNSTEIN-BURKLEY, P.C. X_ By:_ A_ Shawn'P. McClure Attorney for Plaintiff 707 Grant Street Suite 2200—Gulf Tower Pittsburgh, PA 15219 (412) 456-8100 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINNELL, LP, Plaintiff, VS. Civil Action No. 13-1389 FOX SUBACUTE AT MECHANICSBURG, LLC, Defendant. CERTIFICATE OF SERVICE The undersigned, Shawn P. McClure, hereby certifies that a true and correct copy of the foregoing PETITION FOR APPOINTMENT OF ARBITRATORS was served upon the following via regular U.S. Mail, postage prepaid, this O y of April, 2013, addressed as follows: Fox Subacute at Mechanicsburg, LLC. c/o Joseph F. Muray Law Offices of Walter B. Dunsmore 251 Stenton Avenue Plymouth Meeting,PA 19462 Shawn P. McClure, Esquire IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINNELL, LP, Plaintiff, vs. Civil Action No. 13-13 89 FOX SUBACUTE AT MECHANICSBURG, LLC, Defendant. ORDER OF COURT AND NOW, this 164 day of Imo_, 2013, upon consideration of the record and the foregoing petition,) ttwooll (E/sgq., 1"A4� Esq., and Esq. are appointed arbitrators in the above-captioned action as prayed for. By the Court, J. c C xr7l rr? '+ ter; �"- C> Q t r e> Z?- ``, 4�41;v le;.., Lam rev SIMPLEXGRINNELL LP, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW , r � NO. 13-1389 CIVIL Cnr— .r . FOX SUBACUTE AT --� a MECHANICSBURG, LLC cad Defendant r t.- ORDER AND NOW, this Z/* day of May, 2013, the appointment of a Board of Arbitrators in the above-captioned case is VACATED. Kathleen Shaulis, Esquire, Chairman, shall be paid the sum of$50.00. BY THE COURT, 7Kevi . Hess, P. J. ✓Kathleen Shaulis, Esquire Court Administrator :rlm /h Z C-)c) c IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINNELL, LP, Plaintiff, C= VS. Civil Action No. 13-13 89 rn = � _... FOX SUBACUTE AT -<> CO c MECHANICSBURG, LLC, < ="- CD Defendant. PRAECIPE TO SETTLE, DISCONTINUE AND END FILED ON BEHALF OF Plaintiff COUNSEL OF RECORD OF THIS PARTY: SHAWN P. MCCLURE, ESQUIRE PA ID#205951 JENNIFER L. TIS, ESQUIRE PA ID #203751 RAYMOND P. WENDOLOWSKI, JR., ESQUIRE PA ID #311415 Bernstein-Burkley, P.C. Firm#718 Suite 2200 Gulf Tower Pittsburgh, PA 15219 412-456-8100 BERNSTEIN FILE NO. C0077246 601708.doc IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINNELL, LP, Plaintiff, VS. Civil Action No. 13-1389 FOX SUBACUTE AT MECHANICSBURG, LLC, Defendant. PRAECIPE TO SETTLE,DISCONTINUE AND END TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Settle, discontinue and end the above-captioned matter upon the records of the Court and mark the costs paid. BERNSTEIN-BURKLEY, P.C. By: Raymond P. Wendolowski, Jr., Esquire PA ID #311415 Attorneys for Plaintiff Suite 2200 Gulf Tower Commonwealth of Pennsylvania Pittsburgh, PA 15219 County of Allegheny (412)456-8100 BERNSTEIN FILE NO: C0077246 Sworn to and subscrib before me this duav of May, 201 K ') 1bW1A.. \ CJ" Notary Public COMMIONWMTH OF P_NNSYLVANIA Notarfal5eat Turd,Notary Public Gy of pMisburgh,A�iieny County coq nlllNiM1 Dec 78,203A - NOTARIES 601708.doc IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION SIMPLEXGRINNELL, LP, Plaintiff, VS. Civil Action No. 13-1389 FOX SUBACUTE AT MECHANICSBURG, LLC, Defendant. CERTIFICATE OF SERVICE I, Raymond P. Wendolowski, Jr., Esquire,hereby certify that a true and correct copy of the foregoing PRAECIPE TO SETTLE, DISCONTINUE AND END was served on the Defendant by regular U. S. Mail,postage prepaid, this 4 day of May, 2013, addressed as follows: Fox Subacute at Mechanicsburg, LLC c/o Joseph F. Muray, Esquire Law Offices of Walter B. Dunsmore 251 Stenton Avenue Plymouth Meeting,PA 19462 Raymond P. Wendolowski, Jr., Esquire 601708.doc