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Based on facility observation and staff interview and verification, the facility failed to ensure that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure was held open only by devices arranged to automatically close all such doors. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey.

Findings included:

On 02/16/11 between the hours of 1:15 P.M. and 1:30 P.M. tour of the art therapy area was conducted with Staff G. Observation of the art therapy area revealed a small kitchen for patient and staff use. At the entrance to the small kitchen was a door with signage that stated it was a fire door and to keep closed at all times. The door was equipped with a closing device but was held open with a large trash receptacle.

Staff G located a staff person in the area who verified the trash receptacle was placed at the door to keep the door open. Staff G verified the door was a fire door and it was to remain closed at all times.

Based on facility observation and staff interview and verification, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15 and 02/16/11 tour of the facility was conducted with Staff G, H, or K. Observation of the patient care units and rooms on the first and second floors revealed the ceilings were monolithic construction with air handling devices present in the ceilings of the units and rooms. It was not possible to observe and determine that air handling devices were sealed to prevent the passage of smoke above the ceilings.

Corridors on the first floor located near the cafeteria, human resource and art therapy departments indicated the presence of ceiling tiles.

Observations of identified smoke barriers were made through access panels located at the smoke barrier doors on the units. The following penetrations were observed in the spaces above the ceilings.

Second Floor;

* Penetrations were observed on the 2600 unit at both sides of the identified smoke barrier doors. Penetrations were observed on the side of the smoke barrier doors near room 2609 at both upper corners of the barrier wall above the smoke doors. Observation of the other side of the smoke barrier doors revealed penetrations at the roof deck around conduit.

* Both sides of the smoke barrier, above the smoke barrier doors, were observed on the 2500 unit. A penetration was observed in the smoke barrier wall located above the smoke doors near patient room 2505. The open areas were noted at the roof decking and to the right of metal duct work. The area was noted to be approximately 3 inches in diameter. Observation on the other side of the same smoke doors revealed a penetration that surrounded conduit.

First Floor:

* Observation above the smoke doors located on the 1600 wing revealed a penetration that surrounded conduit.

* Observation above the ceiling tiles, at a smoke door located in the corridor near the art therapy rooms, revealed an open area measuring approximately 8 inches in height by 5 feet in width.

Staff present during tour observed and verified the noted penetrations.

Based on facility observation and staff interview and verification, the facility failed to ensure that when the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/16/11, between the hours of 8:50 A.M. and 12:00 P.M. tour of the first floor was conducted with Staff G and K. Observation of the facility revealed the entire facility was provided with automatic sprinkler protection. Located on the 1400 unit of the facility was an environmental closet noted to be sprinklered. Observation of the ceiling tiles in the closet revealed areas of the tiles cut out which surrounded two pipes and conduit.

Observation of the medical record storage area located on the lower level of the facility with Staff G and I between 1:50 P.M. and 2:30 P.M., revealed the room contained a significant amount of paper files for former patients. Staff G stated the room was used to store old files until sent to another storage location. The room was noted to be provided with sprinkler protection. Located in the room were pipes that extended through he ceiling of the room. Ceiling tiles were noted to have square areas cut out of them to accommodate the round pipes.

Staff present on tour observed and verified the penetrations in the ceiling tiles used to provide smoke resistant partitions.
.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15 and 02/16/11 between the hours of 9:00 A.M. and 3:00 P.M. tour of the facility was conducted with Staff G, H, K or I. During tour of the facility, paths of exit egress and points of exit discharge were observed. The following exit discharges were observed to be not maintained to be free of all obstructions or impediments for full and instant use in case of fire or other emergencies.

1. Located on the second floor of the facility was exit stairwell six. Observation of exit stairwell on 02/15/11 revealed exit discharge from the buildging was onto a small concrete pad approximately four feet be four feet square. Travel to the hard surfaced public way required movement across a snow covered grassy area estimated to be fifty feet in length. Staff G stated the paved area closest to the exit was the employee parking area.

2. Observation on the first floor of the exit discharge for stairwell seven, located on the 1500 wing, revealed the exit discharge was to a grassy area covered with packed snow and ice. Travel to a the closest paved area required movement across approximately twenty feet of the uneven, snow packed grassy area.

3. Observation of exit discharge for stairwell two revealed discharge to the exterior of the building was into a courtyard area with a concrete path. The path was observed to be partially covered with a layer of snow and ice.

4. Observation of exit 1317 located near the 1700 unit on the first floor revealed the exit discharge was to a concrete path partially covered with a layer of snow and ice.

Staff G observed all the exit discharges and verified the exits were not maintained to be free of obstruction or impediments to the public way.

Based on facility observation and staff interview and verification, the facility failed to ensure that where special door locking arrangements were permitted in mental health facilities, the use of the locks on patient sleeping rooms were utilized when the clinical needs of the patients required specialized security measures for their safety. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15 and 02/16/11 between the hours of 9:00 A.M. and 3:00 P.M. tour of the facility was conducted with Staff G, H, K or I. During tour of the facility, three of seven patient care units were noted to have patient sleeping rooms with dead bolt type locks on the doors. The units with locks on patient room doors were the 1400 unit, with six patient rooms, 1600 unit, with 13 patient rooms and 2600 unit, with 12 patient rooms. Two patients could occupy a room.

On 02/15/11 Staff G was interview regarding the use of the locks on the patient room doors. Staff G stated that patient room doors were locked when staff did not want the patients to return to their rooms when the patients were to attend individual treatment or group sessions. Staff G further stated that some patients hide in other patient's rooms or in unoccupied rooms. Staff G stated that at no time were patients locked into their sleeping rooms. Staff P verified the procedure for use of locks on patient room doors.

Staff G locked the surveyor in an unoccupied patient room at the surveyor's request. Two actions were required to open the door from inside the room. One action required turning the thumb turn of the dead bolt with the second action pushing on the door handle to release the door.

Further observation of the facility revealed there were special rooms that were not patient sleeping rooms utilized to secure a patient for their safety or to address clinical needs.

Based on facility observation and staff interview, the facility failed to ensure that medical gas storage were protected in accordance with National Fire Protection Association (NFPA)99, Standards for Health Care Facilities. NFPA 99 requirements for storage requirements (location, construction, arrangement) are addressed at 4-3.1.1.2. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/16/11 between 1:45 P.M. and 2:30 P.M. tour of the lower level of the facility was conducted with Staff G and I. Observation of the lower level revealed storage of E sized cylinders of oxygen in an open area. The oxygen was stored in a small boxed in area with a wooden half gate to hold the cylinders in place. The wooden gate was noted to be approximately 3 to 4 feet in height. The half door to the area was locked. Twelve E sized cylinders were observed secured in a cart with 4 others secured to the wall, noted to be full, and at least 3 additional E sized cylinders were secured to the wooden side of the boxed area.

The boxed area used to store the oxygen cylinders was in the path of exit egress and located in close proximity to the exit door.

Staff G verified the area was the facility storage area for oxygen cylinders.

1. Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15 and 02/16/11 between the hours of 9:00 A.M. and 3:00 P.M. tour of the facility was conducted with Staff G, H, K or I. During tour, the facility was observed to have smoke detectors placed in close proximity to air flow devices. The following smoke detectors were observed to be significantly less than 36 inches from air flow devices:

Second Floor:

* A smoke detector located at the recovery unit nursing station.

* A smoke detector located at the recovery unit elevator lobby.

First Floor:

*A smoke detector located at the entrance to the 1400 unit.

* A smoke detector located in the corridor of the 1500 patient care unit.

*A smoke detector located outside the medical record room 1206.

*Three smoke detectors located in the medical records room.

*A smoke detector located in the corridor of the 1700 unit.

*A smoke detector located in the corridor outside the cafeteria

*A smoke detector located in the corridor near the seclusion rooms.

Staff present on tour observed and verified the locations of the smoke detectors
with regards to placement less than 36 inches from air flow devices.

2. Based on review of facility documentation and staff interview and verification, the facility failed to ensure the requirement located in National Fire Protection Association (NFPA) 90-A. Standard for the Installation of Air-Conditioning and Ventilation Systems, 1999, Chapter 3, Integration of a ventilation and air conditioning system(s) with building construction , 3-4.7, fire and smoke dampers, with regards to verification that dampers were checked, that they fully closed; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15/11 review of facility documentation was conducted with regards to testing of the facility smoke and fire dampers. Review of the documentation revealed the tests were completed in March and April 2009. The report indicated that some dampers were not tested as they were not accessible due to building construction.

There were three dampers noted in the lower level, five dampers noted on the first floor and eleven dampers noted on the second floor as being inaccessible for testing. A letter from the local authority having jurisdiction (AHJ) indicated that testing was required but that in order for that to occur it would require extensive work by the facility. The AHJ noted in the letter the expectation would be for the facility to correct the inaccessibility when renovation took place.

Interview of Staff G and I on 02/16/11 at 1:30 P.M. regarding the testing of the dampers and the letter from the AHJ revealed the facility had not completed an assessment or analysis to determine the expense or work required to remedy the situation. Staff G could not address if any other means of testing had been attempted to determine if the inaccessible dampers were functioning or not.

Based on facility observation and staff interview and verification, the facility failed to ensure that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure was held open only by devices arranged to automatically close all such doors. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey.

Findings included:

On 02/16/11 between the hours of 1:15 P.M. and 1:30 P.M. tour of the art therapy area was conducted with Staff G. Observation of the art therapy area revealed a small kitchen for patient and staff use. At the entrance to the small kitchen was a door with signage that stated it was a fire door and to keep closed at all times. The door was equipped with a closing device but was held open with a large trash receptacle.

Staff G located a staff person in the area who verified the trash receptacle was placed at the door to keep the door open. Staff G verified the door was a fire door and it was to remain closed at all times.

Based on facility observation and staff interview and verification, the facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15 and 02/16/11 tour of the facility was conducted with Staff G, H, or K. Observation of the patient care units and rooms on the first and second floors revealed the ceilings were monolithic construction with air handling devices present in the ceilings of the units and rooms. It was not possible to observe and determine that air handling devices were sealed to prevent the passage of smoke above the ceilings.

Corridors on the first floor located near the cafeteria, human resource and art therapy departments indicated the presence of ceiling tiles.

Observations of identified smoke barriers were made through access panels located at the smoke barrier doors on the units. The following penetrations were observed in the spaces above the ceilings.

Second Floor;

* Penetrations were observed on the 2600 unit at both sides of the identified smoke barrier doors. Penetrations were observed on the side of the smoke barrier doors near room 2609 at both upper corners of the barrier wall above the smoke doors. Observation of the other side of the smoke barrier doors revealed penetrations at the roof deck around conduit.

* Both sides of the smoke barrier, above the smoke barrier doors, were observed on the 2500 unit. A penetration was observed in the smoke barrier wall located above the smoke doors near patient room 2505. The open areas were noted at the roof decking and to the right of metal duct work. The area was noted to be approximately 3 inches in diameter. Observation on the other side of the same smoke doors revealed a penetration that surrounded conduit.

First Floor:

* Observation above the smoke doors located on the 1600 wing revealed a penetration that surrounded conduit.

* Observation above the ceiling tiles, at a smoke door located in the corridor near the art therapy rooms, revealed an open area measuring approximately 8 inches in height by 5 feet in width.

Staff present during tour observed and verified the noted penetrations.

Based on facility observation and staff interview and verification, the facility failed to ensure that when the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/16/11, between the hours of 8:50 A.M. and 12:00 P.M. tour of the first floor was conducted with Staff G and K. Observation of the facility revealed the entire facility was provided with automatic sprinkler protection. Located on the 1400 unit of the facility was an environmental closet noted to be sprinklered. Observation of the ceiling tiles in the closet revealed areas of the tiles cut out which surrounded two pipes and conduit.

Observation of the medical record storage area located on the lower level of the facility with Staff G and I between 1:50 P.M. and 2:30 P.M., revealed the room contained a significant amount of paper files for former patients. Staff G stated the room was used to store old files until sent to another storage location. The room was noted to be provided with sprinkler protection. Located in the room were pipes that extended through he ceiling of the room. Ceiling tiles were noted to have square areas cut out of them to accommodate the round pipes.

Staff present on tour observed and verified the penetrations in the ceiling tiles used to provide smoke resistant partitions.
.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15 and 02/16/11 between the hours of 9:00 A.M. and 3:00 P.M. tour of the facility was conducted with Staff G, H, K or I. During tour of the facility, paths of exit egress and points of exit discharge were observed. The following exit discharges were observed to be not maintained to be free of all obstructions or impediments for full and instant use in case of fire or other emergencies.

1. Located on the second floor of the facility was exit stairwell six. Observation of exit stairwell on 02/15/11 revealed exit discharge from the buildging was onto a small concrete pad approximately four feet be four feet square. Travel to the hard surfaced public way required movement across a snow covered grassy area estimated to be fifty feet in length. Staff G stated the paved area closest to the exit was the employee parking area.

2. Observation on the first floor of the exit discharge for stairwell seven, located on the 1500 wing, revealed the exit discharge was to a grassy area covered with packed snow and ice. Travel to a the closest paved area required movement across approximately twenty feet of the uneven, snow packed grassy area.

3. Observation of exit discharge for stairwell two revealed discharge to the exterior of the building was into a courtyard area with a concrete path. The path was observed to be partially covered with a layer of snow and ice.

4. Observation of exit 1317 located near the 1700 unit on the first floor revealed the exit discharge was to a concrete path partially covered with a layer of snow and ice.

Staff G observed all the exit discharges and verified the exits were not maintained to be free of obstruction or impediments to the public way.

Based on facility observation and staff interview and verification, the facility failed to ensure that where special door locking arrangements were permitted in mental health facilities, the use of the locks on patient sleeping rooms were utilized when the clinical needs of the patients required specialized security measures for their safety. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15 and 02/16/11 between the hours of 9:00 A.M. and 3:00 P.M. tour of the facility was conducted with Staff G, H, K or I. During tour of the facility, three of seven patient care units were noted to have patient sleeping rooms with dead bolt type locks on the doors. The units with locks on patient room doors were the 1400 unit, with six patient rooms, 1600 unit, with 13 patient rooms and 2600 unit, with 12 patient rooms. Two patients could occupy a room.

On 02/15/11 Staff G was interview regarding the use of the locks on the patient room doors. Staff G stated that patient room doors were locked when staff did not want the patients to return to their rooms when the patients were to attend individual treatment or group sessions. Staff G further stated that some patients hide in other patient's rooms or in unoccupied rooms. Staff G stated that at no time were patients locked into their sleeping rooms. Staff P verified the procedure for use of locks on patient room doors.

Staff G locked the surveyor in an unoccupied patient room at the surveyor's request. Two actions were required to open the door from inside the room. One action required turning the thumb turn of the dead bolt with the second action pushing on the door handle to release the door.

Further observation of the facility revealed there were special rooms that were not patient sleeping rooms utilized to secure a patient for their safety or to address clinical needs.

Based on facility observation and staff interview, the facility failed to ensure that medical gas storage were protected in accordance with National Fire Protection Association (NFPA)99, Standards for Health Care Facilities. NFPA 99 requirements for storage requirements (location, construction, arrangement) are addressed at 4-3.1.1.2. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/16/11 between 1:45 P.M. and 2:30 P.M. tour of the lower level of the facility was conducted with Staff G and I. Observation of the lower level revealed storage of E sized cylinders of oxygen in an open area. The oxygen was stored in a small boxed in area with a wooden half gate to hold the cylinders in place. The wooden gate was noted to be approximately 3 to 4 feet in height. The half door to the area was locked. Twelve E sized cylinders were observed secured in a cart with 4 others secured to the wall, noted to be full, and at least 3 additional E sized cylinders were secured to the wooden side of the boxed area.

The boxed area used to store the oxygen cylinders was in the path of exit egress and located in close proximity to the exit door.

Staff G verified the area was the facility storage area for oxygen cylinders.

1. Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15 and 02/16/11 between the hours of 9:00 A.M. and 3:00 P.M. tour of the facility was conducted with Staff G, H, K or I. During tour, the facility was observed to have smoke detectors placed in close proximity to air flow devices. The following smoke detectors were observed to be significantly less than 36 inches from air flow devices:

Second Floor:

* A smoke detector located at the recovery unit nursing station.

* A smoke detector located at the recovery unit elevator lobby.

First Floor:

*A smoke detector located at the entrance to the 1400 unit.

* A smoke detector located in the corridor of the 1500 patient care unit.

*A smoke detector located outside the medical record room 1206.

*Three smoke detectors located in the medical records room.

*A smoke detector located in the corridor of the 1700 unit.

*A smoke detector located in the corridor outside the cafeteria

*A smoke detector located in the corridor near the seclusion rooms.

Staff present on tour observed and verified the locations of the smoke detectors
with regards to placement less than 36 inches from air flow devices.

2. Based on review of facility documentation and staff interview and verification, the facility failed to ensure the requirement located in National Fire Protection Association (NFPA) 90-A. Standard for the Installation of Air-Conditioning and Ventilation Systems, 1999, Chapter 3, Integration of a ventilation and air conditioning system(s) with building construction , 3-4.7, fire and smoke dampers, with regards to verification that dampers were checked, that they fully closed; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. The mental health facility had a capacity of 160 beds with a census of 133 patients at the time of the survey. Potentially all patients, staff and visitors in the facility could be affected.

Findings included:

On 02/15/11 review of facility documentation was conducted with regards to testing of the facility smoke and fire dampers. Review of the documentation revealed the tests were completed in March and April 2009. The report indicated that some dampers were not tested as they were not accessible due to building construction.

There were three dampers noted in the lower level, five dampers noted on the first floor and eleven dampers noted on the second floor as being inaccessible for testing. A letter from the local authority having jurisdiction (AHJ) indicated that testing was required but that in order for that to occur it would require extensive work by the facility. The AHJ noted in the letter the expectation would be for the facility to correct the inaccessibility when renovation took place.

Interview of Staff G and I on 02/16/11 at 1:30 P.M. regarding the testing of the dampers and the letter from the AHJ revealed the facility had not completed an assessment or analysis to determine the expense or work required to remedy the situation. Staff G could not address if any other means of testing had been attempted to determine if the inaccessible dampers were functioning or not.