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Based on observation and interview, the facility failed to provide interior finish material that meet the flame spread requirements of NFPA 101-2000 edition, Sections 19.3.3.1, 19.3.3.2 and 10.2.3. This deficient practice could affect approximately 8 of 25 patients, staff and visitors.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observation revealed that on the east wall of the mechanical room located in the behavioral health unit storage suite had a non rated foam acoustical foam padding affixed to the interior of the wall. This finding was further qualified by the Maintenance Director who revealed that the facility had no documentation on the interior finish flame spread rating of the foam acoustical padding material.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the facility had penetrations in the corridors that are not in compliance with NFPA Life Safety Code 101 (00) Sections 19.3.6.2 and 8.2.4.4.1 in resisting the passage of smoke. This deficient practice could affect the exiting of patients, staff and visitors. In the event of a fire in this space, smoke and fire could spread into the corridor making it untenable.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, it was observed that the facility had numerous 1/4 inch gaps around sprinkler heads and penetrations in the ceiling tiles located throughout the facility's corridors.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the facility has failed to provide proper protection for several corridor smoke barrier doors throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.6.3.1., and NFPA 80 Fire Doors and Fire Windows (99) The following deficient practice could negatively affect the patients, staff, and visitors as smoke could migrate between smoke barriers making the corridor untenable.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observation revealed, that there were several smoke barrier corridor doors that had gaps between the doors located by room 3002 and 3018 that are between 1/4 to 3/8 of an inch which are greater than the acceptable maximum gap of 1/8 of an inch.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the facility has failed to provide proper protection for several corridor smoke barrier doors throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.6.3.1., and NFPA 80 Fire Doors and Fire Windows (99) The following deficient practice could negatively affect the patients, staff, and visitors as smoke could migrate between smoke barriers making the corridor untenable.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observation revealed, that there were several smoke barrier corridor doors that had gaps between the doors that are between 1/4 to 3/8 of an inch which are greater than the acceptable maximum gap of 1/8 of an inch.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 18.3.2.1. The following deficient practice could negatively affect patients, staff, and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observation revealed, that there were several penetration in the wall around the pipes and conduit located in the electrical panel rooms 3138 and 2269 separating the room from the corridor, and the door to the equipment storage room 3136 did not fully close and latch into the door frame.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 19.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during the review of available emergency battery back up exit lighting maintenance documentation and interview with the Maintenance Director (JG) the following deficient conditions were revealed affecting the battery back-up emergency lighting:

1. The that the facility failed to conduct and document the annual 90 minute test for the battery back-up lighting within the last 12 months.

2. 2 of 4 battery back-up lights were inoperative when they were tested at the time of the inspection.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect all patients, visitors and staff of the facility.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observations reveled that the spare sprinkler head box was not equipped with at least 2 of every type and style of sprinkler heads that are being used in the facility. The observed missing spare sprinkler heads were the high temperature heads like the ones located in boiler rooms and in the central storage room.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect all patients, visitors and staff of the facility.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observations reveled the following deficient conditions affecting the fire sprinkler system:

1. The spare sprinkler head box was not equipped with at least 2 of every type and style of sprinkler heads that are being used in the facility. The observed missing spare sprinkler heads were the high temperature heads like the ones located in boiler and mechanical rooms.

2. The facility was also missing escutcheon rings in room 3110 and 2425.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on a records review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures for conducting a hazard assessment in accordance with NFPA 99 Health Care Facilities Handbook (99) section 10-2.1.1.1. This deficient practice could affect the facility's ability mitigate hazards associated with the functions of the hospitals laboratory, which could affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during record review and an interview with the Maintenance Director (JG) and the available staff in the hospital's laboratory, it was revealed that the staff could not locate, access or produce the hazard assessment policies used in the laboratory.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on a records review and staff interview, the facility has failed to provide any documentation verifying the completion of any orientation and training or continuing safety education in accordance with NFPA 99 Health Care Facilities Handbook (99) section 10-2.1.4. This deficient practice could affect the facility's ability mitigate hazards associated with the functions of the hospitals laboratory, which could affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during record review and an interview with the Maintenance Director (JG) and the available staff in the hospital's laboratory, it was revealed that the staff could not locate, access or produce the any documentation that verified that the required safety training has been conducted within the last 12 months for the laboratory staff members.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during record review and an interview with the Director of Maintenance Director (JG), the facility failed to update and provide a complete list of contact information on the automatic fire alarm system out of service policy. The policy was lacking any current and accurate contact information for the Deputy State Fire Marshal that is responsible for that facility.




These deficient practices were confirmed by the Maintenance Director (JG).

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during record review and an interview with the Director of Maintenance Director (JG), the facility failed to update and provide a complete list of contact information on the automatic fire alarm system out of service policy. The policy was lacking any current and accurate contact information for the Deputy State Fire Marshal that is responsible for that facility.



These deficient practices were confirmed by the Maintenance Director (JG).

Based on observation and interview, the facility failed to provide interior finish material that meet the flame spread requirements of NFPA 101-2000 edition, Sections 19.3.3.1, 19.3.3.2 and 10.2.3. This deficient practice could affect approximately 8 of 25 patients, staff and visitors.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observation revealed that on the east wall of the mechanical room located in the behavioral health unit storage suite had a non rated foam acoustical foam padding affixed to the interior of the wall. This finding was further qualified by the Maintenance Director who revealed that the facility had no documentation on the interior finish flame spread rating of the foam acoustical padding material.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the facility had penetrations in the corridors that are not in compliance with NFPA Life Safety Code 101 (00) Sections 19.3.6.2 and 8.2.4.4.1 in resisting the passage of smoke. This deficient practice could affect the exiting of patients, staff and visitors. In the event of a fire in this space, smoke and fire could spread into the corridor making it untenable.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, it was observed that the facility had numerous 1/4 inch gaps around sprinkler heads and penetrations in the ceiling tiles located throughout the facility's corridors.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the facility has failed to provide proper protection for several corridor smoke barrier doors throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.6.3.1., and NFPA 80 Fire Doors and Fire Windows (99) The following deficient practice could negatively affect the patients, staff, and visitors as smoke could migrate between smoke barriers making the corridor untenable.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observation revealed, that there were several smoke barrier corridor doors that had gaps between the doors located by room 3002 and 3018 that are between 1/4 to 3/8 of an inch which are greater than the acceptable maximum gap of 1/8 of an inch.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the facility has failed to provide proper protection for several corridor smoke barrier doors throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.6.3.1., and NFPA 80 Fire Doors and Fire Windows (99) The following deficient practice could negatively affect the patients, staff, and visitors as smoke could migrate between smoke barriers making the corridor untenable.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observation revealed, that there were several smoke barrier corridor doors that had gaps between the doors that are between 1/4 to 3/8 of an inch which are greater than the acceptable maximum gap of 1/8 of an inch.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 18.3.2.1. The following deficient practice could negatively affect patients, staff, and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observation revealed, that there were several penetration in the wall around the pipes and conduit located in the electrical panel rooms 3138 and 2269 separating the room from the corridor, and the door to the equipment storage room 3136 did not fully close and latch into the door frame.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 19.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during the review of available emergency battery back up exit lighting maintenance documentation and interview with the Maintenance Director (JG) revealed the that the facility failed to conduct and document the annual 90 minute test for the battery back up lighting within the last 12 months.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 19.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during the review of available emergency battery back up exit lighting maintenance documentation and interview with the Maintenance Director (JG) the following deficient conditions were revealed affecting the battery back-up emergency lighting:

1. The that the facility failed to conduct and document the annual 90 minute test for the battery back-up lighting within the last 12 months.

2. 2 of 4 battery back-up lights were inoperative when they were tested at the time of the inspection.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect all patients, visitors and staff of the facility.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observations reveled that the spare sprinkler head box was not equipped with at least 2 of every type and style of sprinkler heads that are being used in the facility. The observed missing spare sprinkler heads were the high temperature heads like the ones located in boiler rooms and in the central storage room.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect all patients, visitors and staff of the facility.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, observations reveled the following deficient conditions affecting the fire sprinkler system:

1. The spare sprinkler head box was not equipped with at least 2 of every type and style of sprinkler heads that are being used in the facility. The observed missing spare sprinkler heads were the high temperature heads like the ones located in boiler and mechanical rooms.

2. The facility was also missing escutcheon rings in room 3110 and 2425.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 Life Safety Code (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, a review of documentation and interview with the Maintenance Director (JG), revealed the facility failed to provide documentation for 2 out of the last 4 quarterly fire sprinkler flow tests inspections and for the annual fire sprinkler test as required by NFPA 13(99) and NFPA 25(98).


These deficient practices were confirmed by the Maintenance Director (JG).

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, documentation review of the emergency generator testing logs indicated that the facility failed to conduct 40 of 52 weekly inspections of the Type I emergency generator from February 2013 to the date of this inspection.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during record review and an interview with the Maintenance Director (JG), revealed that the facility failed to update and provide a complete list of contact information on the automatic fire sprinkler system out of service policy. The policy was lacking any current and accurate contact information for the Deputy State Fire Marshal that is responsible for that facility.


These deficient practices were confirmed by the Maintenance Director (JG).

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during record review and an interview with the Director of Maintenance Director (JG), the facility failed to update and provide a complete list of contact information on the automatic fire alarm system out of service policy. The policy was lacking any current and accurate contact information for the Deputy State Fire Marshal that is responsible for that facility.




These deficient practices were confirmed by the Maintenance Director (JG).

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for four or more hours in a 24 hour period. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all patients, visitors and staff.


Findings include:

On facility tour between 9:30 AM and 5:30 PM on 02/26/2014, during record review and an interview with the Director of Maintenance Director (JG), the facility failed to update and provide a complete list of contact information on the automatic fire alarm system out of service policy. The policy was lacking any current and accurate contact information for the Deputy State Fire Marshal that is responsible for that facility.



These deficient practices were confirmed by the Maintenance Director (JG).