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Based on observation and staff interviews, it was observed that the facility was not in accordance to NFPA 101-Life Safety Code [2000 Ed] Sections 19.5.2.1 and 9.2.1, and additionally in NFPA 90A [1999 Ed] Section 3-4.7 as evidenced by the following items. This deficiency could affect all of the patients, staff and visitors within the two smoke compartments of this psychiatric hospital.

Findings include:
1. On January 26, 2015 at 10:29 AM surveyor #14105 observed that during a review of documents it was discovered that dampers were missing at the following locations:
A) the penthouse air handling unit, AC #2, which feeds the hospital wing, had main supply and return ducts that did not have fire dampers at the bottom of their respective masonry shafts that extended from the penthouse, through the 4th & 2nd levels to a crawl space located below the 2nd level.
B) approximately 20 duct penetrations through the level 2 floor did not have fire dampers. The 5 " x12 " ducts in the crawl space passed through the level 2 floor, without dampers, to feed the floor mounted ventilation units on that floor. These ducts exceeded the maximum size permitted by the exception in section 903 to not have fire dampers.
C) about 6-8 supply and return ducts did not have fire dampers where they penetrated the penthouse and 4th level floors to serve the overhead ventilation grills on the 2nd level in the center core of the hospital space located below the footprint of the penthouse.

2. On January 26, 2015 at 11:13 AM surveyor #14105 observed that during a walk-through of the facility that the two offices and the kitchenette were not provided with a supply grille within each room. Only a return air grille was installed within these rooms. The supply air was being taken from the corridor and transferred under the doorway. This condition does not meet Section 19.3.6.4 of NFPA 101 (2000 Ed).

An existing waiver exists for Item #1 within this k-tag. These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff P (Maintenance Supervisor).

Based on observation and interview the facility failed to provide electrical wiring and equipment in accordance to NFPA 70 section 9.1.2 and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff and visitors within the two smoke compartments of this psychiatric hospital.

Findings include:
1. On January 26th, 2015 at 12:23 PM, it was observed within the housekeeping closet east of the elevator has a junction box within the room that did not have the cover plate securely fastened into to place. This was an unsafe condition which could result in an electrical shock to a staff member.
2. On January 26th, 2015 at 12:25 PM, it was observed within the laundry room of the lower level a washing machine had an electrical cover plate open. Staff indicated that this plate was off to allow them to make changes to the machine settings. This was an unsafe condition which could result in an electrical shock to a staff member.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Maintenance Director).

Based on observation and staff interviews, it was observed that the facility was not in accordance to NFPA 101-Life Safety Code [2000 Ed] Sections 19.5.2.1 and 9.2.1, and additionally in NFPA 90A [1999 Ed] Section 3-4.7 as evidenced by the following items. This deficiency could affect all of the patients, staff and visitors within the two smoke compartments of this psychiatric hospital.

Findings include:
1. On January 26, 2015 at 10:29 AM surveyor #14105 observed that during a review of documents it was discovered that dampers were missing at the following locations:
A) the penthouse air handling unit, AC #2, which feeds the hospital wing, had main supply and return ducts that did not have fire dampers at the bottom of their respective masonry shafts that extended from the penthouse, through the 4th & 2nd levels to a crawl space located below the 2nd level.
B) approximately 20 duct penetrations through the level 2 floor did not have fire dampers. The 5 " x12 " ducts in the crawl space passed through the level 2 floor, without dampers, to feed the floor mounted ventilation units on that floor. These ducts exceeded the maximum size permitted by the exception in section 903 to not have fire dampers.
C) about 6-8 supply and return ducts did not have fire dampers where they penetrated the penthouse and 4th level floors to serve the overhead ventilation grills on the 2nd level in the center core of the hospital space located below the footprint of the penthouse.

2. On January 26, 2015 at 11:13 AM surveyor #14105 observed that during a walk-through of the facility that the two offices and the kitchenette were not provided with a supply grille within each room. Only a return air grille was installed within these rooms. The supply air was being taken from the corridor and transferred under the doorway. This condition does not meet Section 19.3.6.4 of NFPA 101 (2000 Ed).

An existing waiver exists for Item #1 within this k-tag. These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff P (Maintenance Supervisor).

Based on observation and interview the facility failed to provide electrical wiring and equipment in accordance to NFPA 70 section 9.1.2 and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff and visitors within the two smoke compartments of this psychiatric hospital.

Findings include:
1. On January 26th, 2015 at 12:23 PM, it was observed within the housekeeping closet east of the elevator has a junction box within the room that did not have the cover plate securely fastened into to place. This was an unsafe condition which could result in an electrical shock to a staff member.
2. On January 26th, 2015 at 12:25 PM, it was observed within the laundry room of the lower level a washing machine had an electrical cover plate open. Staff indicated that this plate was off to allow them to make changes to the machine settings. This was an unsafe condition which could result in an electrical shock to a staff member.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Maintenance Director).