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3. At 3:02 p.m., the recessed sprinklers(3) in room 315 were missing covers exposing 3-inch diameter penetrations in the ceiling.



29626

Based on observation, the facility failed to maintain the integrity of the building construction in 3 of 4 smoke compartments. This was evidenced by unsealed penetrations in the facility's walls and ceilings. This could result in the spread of fire and smoke to other compartments. This had the potential of harming residents and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the facility's Life Safety Consultant and the Director of Facilities on 2/1/11, the walls and ceilings were observed.

1. At 2:57 p.m., there were two penetrations that measured approximately 1/2-inch diameter on the wall to Room 56, Consult Room. The wall was adjacent to the corridor.

2. At 3:15 p.m., there was a penetration that measured approximately 1/2-inch diameter on the wall to Group Room in PICU unit. The wall was adjacent to the corridor.

6. At 1:04 p.m., the roll down window, protecting the corridor from the receptionist area, was blocked from fully closing by a computer monitor, telephone and binders.

7. At 2:18 p.m., there was a 1-inch diameter penetration in the corridor wall by the ASU-1 Group room.





29626

Based on observation, the facility failed to maintain the integrity of the building construction of the corridor wall located in 3 of 4 smoke compartments. This was evidenced by unsealed penetrations in the facility's corridor walls that could result in the spread of fire and smoke. This had the potential of harming residents and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the facility's Life Safety Consultant and the Director of Facilites on 2/1/11, the corridor walls were observed.

1. At 1:45 p.m., there were nine circular penetrations on the wall to the ASU I Nursing Station. Five penetrations measured approximately 1/2-inch diameter and four penetration measured approximately 1/4-inch diameter. The wall was exposed to the egress path of the corridor.

2. At 2:07 p.m., there was a penetration to the wall that was underneath the sink in the ASU I Nursing Station. The penetration surrounded a draining pipe that measured approximately 6-inches by 2-inches. The wall was exposed to the egress path of the corridor.

3. At 2:15 p.m., there was a circular penetration on the corridor wall by the Consult Room in the ASU II unit that measured approximately 2-inches diameter.

4. At 2:58 p.m., there were two penetrations on the wall to the corridor adjacent to Room 56, Consult Room. Each penetration measured approximately 1/2-inch diameter.

5. At 3:10 p.m., there were four penetrations on the wall to the corridor by Room 114 in PICU unit. Each penetration measured approximately 1/2-inch diameter.

5. At 1:55 p.m., the door to the ASU-1 TV Lounge was held open by a door wedge.

6. At 1:56 p.m., the door to the Nurse Station from the ASU-2 hallway was held open by a door wedge.

7. At 3:02 p.m., the corridor door to the Senior's TV room was held open by a door wedge.

8. At 3:15 p.m., the door to the Adolescent Partial Program room in the Intensive Care Unit was held open by a door wedge.



29626

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by door stoppers used on doors, affecting 4 of 4 smoke compartments. This had the potential of not being able to quickly close doors in the event of a fire, resulting in the rapid spread of fire and/or smoke to or from other areas of the facility.

Findings include:

During a tour of the facility with the facility's Life Safety Consultant and Director of Facilities on 2/1/11, the corridor doors were observed.

1. At 2:45 p.m., a door stopper held the door open to the Human Resource Office.

2. At 2:46 p.m., a door stopper held the door open to the Business Office.

3. At 2:59 p.m., a door stopper held the door open to Room 58, IOP Office.

4. At 3:21 p.m., a door stopper held the door open to the Group Room in the Adolescent Unit.

Based on observation, the facility failed to ensure that smoke barrier doors positively latch upon closing when released from the door magnets upon activation of the fire alarm system. This was evidenced by 1 of 2 leaf doors equipped with a self-closing latching mechanism that failed to positively latch. This affected 2 of 4 smoke compartments and had the potential of rapidly spreading smoke and fire from one smoke compartment to the next, resulting in injury to residents from smoke inhalation and burns.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Findings:

During a tour of the facility with the Director of Plant Operations and the Life Safety Consultant on 2/1/11, fire barrier doors were observed. At 1:12 p.m., 1 of 2 leaf doors by the Plant Operation Office failed to positively latch upon the activation of a smoke detector connected to the fire alarm system. Both doors were equipped with a self-closing latching mechanism.

Based on observation and interview, the facility failed to ensure that manual pull stations were not blocked from immediate access. This was evidenced by a manual pull station in the outpatient area that was blocked from immediate access. This could result in delay in activating the fire alarm.

Findings:

During the observations of the fire alarm devices with the Director of Facilities on 2/1/11 at 1:22 p.m., the manual pull station located by the entrance to the outpatient clinic was blocked by a couch. The Director of Facilities stated that they were in the process of replacing the furnitures and the couch blocking the pull station was placed in that location temporarily.

Based on observation and interview, the facility failed to maintain a path of egress free from obstructions. This was evidenced by a couch blocking half of the corridor. This could result in delayed egress and injury to patients.

Findings:

During the observation of the means of egress with the Director of Facilities on 2/1/11 at 1:23 p.m., the corridor leading to the outpatient exit was blocked by a couch. The couch was placed in the corridor to be used by patients while waiting for appointments. The Director of Facilities stated that the they are in the process of replacing furnitures.

Based on observation and interview, the facility failed to maintain their emergency back-up power. This was evidenced by a broken remote alarm annunciator for the generator. This could result in failure to monitor the condition of the generator when running.

Findings:

On 2/1/11, the generator emergency electrical back-up power was observed and the maintenance records were reviewed with the Director of facilities.

1. At 1:26 p.m., the remote alarm annunciator for the generator located on the wall in ASU -1 Nurse Station was not lighted. The Director of Maintenance sated on 2/1/11 at 1: 27 p.m., that the annunciator had been broken since he started working for the facility 8 years ago. The facility tried to fix it several times but failed.

2. During the review of the generator maintenance documents, there was no record for the weekly generator visual inspection. The Director of Maintenance Stated that they inspect the generator weekly but did not keep records.

3. At 3:02 p.m., the recessed sprinklers(3) in room 315 were missing covers exposing 3-inch diameter penetrations in the ceiling.



29626

Based on observation, the facility failed to maintain the integrity of the building construction in 3 of 4 smoke compartments. This was evidenced by unsealed penetrations in the facility's walls and ceilings. This could result in the spread of fire and smoke to other compartments. This had the potential of harming residents and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the facility's Life Safety Consultant and the Director of Facilities on 2/1/11, the walls and ceilings were observed.

1. At 2:57 p.m., there were two penetrations that measured approximately 1/2-inch diameter on the wall to Room 56, Consult Room. The wall was adjacent to the corridor.

2. At 3:15 p.m., there was a penetration that measured approximately 1/2-inch diameter on the wall to Group Room in PICU unit. The wall was adjacent to the corridor.

6. At 1:04 p.m., the roll down window, protecting the corridor from the receptionist area, was blocked from fully closing by a computer monitor, telephone and binders.

7. At 2:18 p.m., there was a 1-inch diameter penetration in the corridor wall by the ASU-1 Group room.





29626

Based on observation, the facility failed to maintain the integrity of the building construction of the corridor wall located in 3 of 4 smoke compartments. This was evidenced by unsealed penetrations in the facility's corridor walls that could result in the spread of fire and smoke. This had the potential of harming residents and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the facility's Life Safety Consultant and the Director of Facilites on 2/1/11, the corridor walls were observed.

1. At 1:45 p.m., there were nine circular penetrations on the wall to the ASU I Nursing Station. Five penetrations measured approximately 1/2-inch diameter and four penetration measured approximately 1/4-inch diameter. The wall was exposed to the egress path of the corridor.

2. At 2:07 p.m., there was a penetration to the wall that was underneath the sink in the ASU I Nursing Station. The penetration surrounded a draining pipe that measured approximately 6-inches by 2-inches. The wall was exposed to the egress path of the corridor.

3. At 2:15 p.m., there was a circular penetration on the corridor wall by the Consult Room in the ASU II unit that measured approximately 2-inches diameter.

4. At 2:58 p.m., there were two penetrations on the wall to the corridor adjacent to Room 56, Consult Room. Each penetration measured approximately 1/2-inch diameter.

5. At 3:10 p.m., there were four penetrations on the wall to the corridor by Room 114 in PICU unit. Each penetration measured approximately 1/2-inch diameter.

5. At 1:55 p.m., the door to the ASU-1 TV Lounge was held open by a door wedge.

6. At 1:56 p.m., the door to the Nurse Station from the ASU-2 hallway was held open by a door wedge.

7. At 3:02 p.m., the corridor door to the Senior's TV room was held open by a door wedge.

8. At 3:15 p.m., the door to the Adolescent Partial Program room in the Intensive Care Unit was held open by a door wedge.



29626

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by door stoppers used on doors, affecting 4 of 4 smoke compartments. This had the potential of not being able to quickly close doors in the event of a fire, resulting in the rapid spread of fire and/or smoke to or from other areas of the facility.

Findings include:

During a tour of the facility with the facility's Life Safety Consultant and Director of Facilities on 2/1/11, the corridor doors were observed.

1. At 2:45 p.m., a door stopper held the door open to the Human Resource Office.

2. At 2:46 p.m., a door stopper held the door open to the Business Office.

3. At 2:59 p.m., a door stopper held the door open to Room 58, IOP Office.

4. At 3:21 p.m., a door stopper held the door open to the Group Room in the Adolescent Unit.

Based on observation, the facility failed to ensure that smoke barrier doors positively latch upon closing when released from the door magnets upon activation of the fire alarm system. This was evidenced by 1 of 2 leaf doors equipped with a self-closing latching mechanism that failed to positively latch. This affected 2 of 4 smoke compartments and had the potential of rapidly spreading smoke and fire from one smoke compartment to the next, resulting in injury to residents from smoke inhalation and burns.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Findings:

During a tour of the facility with the Director of Plant Operations and the Life Safety Consultant on 2/1/11, fire barrier doors were observed. At 1:12 p.m., 1 of 2 leaf doors by the Plant Operation Office failed to positively latch upon the activation of a smoke detector connected to the fire alarm system. Both doors were equipped with a self-closing latching mechanism.

Based on observation and interview, the facility failed to ensure that manual pull stations were not blocked from immediate access. This was evidenced by a manual pull station in the outpatient area that was blocked from immediate access. This could result in delay in activating the fire alarm.

Findings:

During the observations of the fire alarm devices with the Director of Facilities on 2/1/11 at 1:22 p.m., the manual pull station located by the entrance to the outpatient clinic was blocked by a couch. The Director of Facilities stated that they were in the process of replacing the furnitures and the couch blocking the pull station was placed in that location temporarily.

Based on observation and interview, the facility failed to maintain a path of egress free from obstructions. This was evidenced by a couch blocking half of the corridor. This could result in delayed egress and injury to patients.

Findings:

During the observation of the means of egress with the Director of Facilities on 2/1/11 at 1:23 p.m., the corridor leading to the outpatient exit was blocked by a couch. The couch was placed in the corridor to be used by patients while waiting for appointments. The Director of Facilities stated that the they are in the process of replacing furnitures.

Based on observation and interview, the facility failed to maintain their emergency back-up power. This was evidenced by a broken remote alarm annunciator for the generator. This could result in failure to monitor the condition of the generator when running.

Findings:

On 2/1/11, the generator emergency electrical back-up power was observed and the maintenance records were reviewed with the Director of facilities.

1. At 1:26 p.m., the remote alarm annunciator for the generator located on the wall in ASU -1 Nurse Station was not lighted. The Director of Maintenance sated on 2/1/11 at 1: 27 p.m., that the annunciator had been broken since he started working for the facility 8 years ago. The facility tried to fix it several times but failed.

2. During the review of the generator maintenance documents, there was no record for the weekly generator visual inspection. The Director of Maintenance Stated that they inspect the generator weekly but did not keep records.