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Based on observation and interview, the facility did not have corridor doors that meets the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of the patients within the smoke compartments.

Findings include:
On facility tour between 9:00 AM 4:00: PM on 10/19/2015, it was observed that :

1. Seclusion Rooms 1B030 & 1B031 - B Unit were equipped with manual dead bolt hasps
2. Seclusion Rooms 1C030 & 1C031 - C Unit were equipped with manual dead bolt hasps
3. Seclusion Rooms 1D030 & 1D031 - D Unit were equipped with manual dead bolt hasps
4. Seclusion Rooms 1E030 & 1E031 - E Unit were equipped with manual dead bolt hasps
5. Seclusion Rooms 1G030 & 1G031 - G Unit were equipped with manual dead bolt hasps
6. Seclusion Rooms 1H030 & 1H031 - H Unit were equipped with manual dead bolt hasps

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation, the facility failed to maintain the smoke barrier in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.7, 19.3.7.3, 8.3, 8.3.2 and 8.3.6.

Findings include:
On facility tour between 9:00 AM 4:00: PM on 10/19/2015, it was observed that:

1. Two 3/4 diameter holes that penetrated the 1 hour smoke barrier wall above the ceiling tile in the Unit G Entry 1G088 doors. The holes are directly above the tile with the exit sign.

2. The installation of a nonrated clear vision panel has downgraded the fire rating of the 1hour fire rated barrier walls that are located throughout the facility.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation and interview, the facility failed to provide protection of hazardous areas in accordance with the requirements of NFPA 101 -2000 edition, Section 19.3.2.1 and 8.4.1

Findings include:
On facility tour between 9:00 AM 4:00: PM on 10/19/2015, it was observed that the door B024 to the Soiled Linen/Utility room located in the B Unit did not fully close and positively latch into the door frame.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation and interview, the facility has failed to provide a proper exit to the outside. This deficient practice could affect the safe and rapid evacuation of all patients and staff in the event of an emergency that may require quick evacuation in accordance with section 7.1. 19.2.1

Findings include:
On facility tour between 9:00 AM to 4:00: PM on 10/19/2015, it was observed that the following exit vestibules were arranged with two doors in the egress path that are locked and need a key to be unlocked to exit the building in the event of an emergency:in the following areas:

1. Exit vestibule 1B057 & 1B079 - B Unit
2. Exit vestibule 1C057 & 1C079 - C Unit
3. Exit vestibule 1D057 & 1D079 - D Unit
4. Exit vestibule 1E057 & 1E079 - E Unit
5. Exit vestibule 1G057 & 1G079 - G Unit
6. Exit vestibule 1H057 & 1H079 - H Unit

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation, the facility has failed to properly maintain the fire alarm system in accordance with NFPA 72, 1999 Edition.

Findings include:
On facility tour between 09:00 AM to 4:00: PM on 10/19/2015, it was observed that:
1. The smoke detector in Unit H by door 1H026 was within 36 inches of the HVAC diffuser.
2. The smoke detector in the link by the A & B Gym doors was within 36 inches of a HVAC diffuser.
3. The smoke detector in Unit D by door 1D025 was within 36 inches of the HVAC diffuser.
4. The smoke detector in Unit B by door 1B005 was within 36 inches of the HVAC diffuser.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation and interview, the facility failed to install the sprinkler system in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.5 and 9.7: NFPA 13 - 1999 edition, Sections 5-1.1, 5-6.3.4, 5-6.5.2.3 and 5-13.8.1.

Findings include:
On facility tour between 09:00 AM to 4:00: PM on 10/19/2015, it was observed that:
1. In the fire sprinkler control room for Units G & H there was a electrical wiring conduit that was attached to the fire sprinkler piping with metal wires.
2. The Fire Department Connection (FDC) is located in the Unit G fenced in courtyard that is locked and not accessible for fire department connection in the event of an emergency.
3. In the Unit C day room there is a sprinkler head that is missing its escutcheon ring.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation, and interview the complete automatic fire sprinkler system is not being maintained in accordance with NFPA 25(99) Section 9.2.7.

Findings include:
On facility tour between 9:00 AM to 4:00: PM on 10/19/2015, it was observed that there are multiple dirty fire sprinkler heads located throughout the kitchen in Unit A.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. section 9.1.2.

Findings include:
On facility tour between 9:00 AM to 4:00: PM on 10/19/2015, it was observed that in the Unit B nurses station there is a power strip suspended from the wall outlet that had a refrigerator plugged into it. The power strip cannot be suspended by the plug and the refrigerator needs to be plugged directly into a wall outlet.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation and interview, the facility did not have corridor doors that meets the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of the patients within the smoke compartments.

Findings include:
On facility tour between 9:00 AM 4:00: PM on 10/19/2015, it was observed that :

1. Seclusion Rooms 1B030 & 1B031 - B Unit were equipped with manual dead bolt hasps
2. Seclusion Rooms 1C030 & 1C031 - C Unit were equipped with manual dead bolt hasps
3. Seclusion Rooms 1D030 & 1D031 - D Unit were equipped with manual dead bolt hasps
4. Seclusion Rooms 1E030 & 1E031 - E Unit were equipped with manual dead bolt hasps
5. Seclusion Rooms 1G030 & 1G031 - G Unit were equipped with manual dead bolt hasps
6. Seclusion Rooms 1H030 & 1H031 - H Unit were equipped with manual dead bolt hasps

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation, the facility failed to maintain the smoke barrier in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.7, 19.3.7.3, 8.3, 8.3.2 and 8.3.6.

Findings include:
On facility tour between 9:00 AM 4:00: PM on 10/19/2015, it was observed that:

1. Two 3/4 diameter holes that penetrated the 1 hour smoke barrier wall above the ceiling tile in the Unit G Entry 1G088 doors. The holes are directly above the tile with the exit sign.

2. The installation of a nonrated clear vision panel has downgraded the fire rating of the 1hour fire rated barrier walls that are located throughout the facility.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation and interview, the facility failed to provide protection of hazardous areas in accordance with the requirements of NFPA 101 -2000 edition, Section 19.3.2.1 and 8.4.1

Findings include:
On facility tour between 9:00 AM 4:00: PM on 10/19/2015, it was observed that the door B024 to the Soiled Linen/Utility room located in the B Unit did not fully close and positively latch into the door frame.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation and interview, the facility has failed to provide a proper exit to the outside. This deficient practice could affect the safe and rapid evacuation of all patients and staff in the event of an emergency that may require quick evacuation in accordance with section 7.1. 19.2.1

Findings include:
On facility tour between 9:00 AM to 4:00: PM on 10/19/2015, it was observed that the following exit vestibules were arranged with two doors in the egress path that are locked and need a key to be unlocked to exit the building in the event of an emergency:in the following areas:

1. Exit vestibule 1B057 & 1B079 - B Unit
2. Exit vestibule 1C057 & 1C079 - C Unit
3. Exit vestibule 1D057 & 1D079 - D Unit
4. Exit vestibule 1E057 & 1E079 - E Unit
5. Exit vestibule 1G057 & 1G079 - G Unit
6. Exit vestibule 1H057 & 1H079 - H Unit

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation, the facility has failed to properly maintain the fire alarm system in accordance with NFPA 72, 1999 Edition.

Findings include:
On facility tour between 09:00 AM to 4:00: PM on 10/19/2015, it was observed that:
1. The smoke detector in Unit H by door 1H026 was within 36 inches of the HVAC diffuser.
2. The smoke detector in the link by the A & B Gym doors was within 36 inches of a HVAC diffuser.
3. The smoke detector in Unit D by door 1D025 was within 36 inches of the HVAC diffuser.
4. The smoke detector in Unit B by door 1B005 was within 36 inches of the HVAC diffuser.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation and interview, the facility failed to install the sprinkler system in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.5 and 9.7: NFPA 13 - 1999 edition, Sections 5-1.1, 5-6.3.4, 5-6.5.2.3 and 5-13.8.1.

Findings include:
On facility tour between 09:00 AM to 4:00: PM on 10/19/2015, it was observed that:
1. In the fire sprinkler control room for Units G & H there was a electrical wiring conduit that was attached to the fire sprinkler piping with metal wires.
2. The Fire Department Connection (FDC) is located in the Unit G fenced in courtyard that is locked and not accessible for fire department connection in the event of an emergency.
3. In the Unit C day room there is a sprinkler head that is missing its escutcheon ring.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Based on observation, and interview the complete automatic fire sprinkler system is not being maintained in accordance with NFPA 25(99) Section 9.2.7.

Findings include:
On facility tour between 9:00 AM to 4:00: PM on 10/19/2015, it was observed that there are multiple dirty fire sprinkler heads located throughout the kitchen in Unit A.

This deficient practice was verified by the facility Director (DR), at the time of discovery.

Electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. section 9.1.2.

Findings include:
On facility tour between 9:00 AM to 4:00: PM on 10/19/2015, it was observed that in the Unit B nurses station there is a power strip suspended from the wall outlet that had a refrigerator plugged into it. The power strip cannot be suspended by the plug and the refrigerator needs to be plugged directly into a wall outlet.

This deficient practice was verified by the facility Director (DR), at the time of discovery.