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1) Based on observation and interview, the facility failed to maintain 2 of 3 fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Section 7.3.1.1.1 requires that fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification. Section 3.3.15 defines extinguisher maintenance as a thorough examination of the fire extinguisher that is intended to give maximum assurance that a fire extinguisher will operate effectively and safely and to determine if physical damage or condition will prevent its operation, if any repair or replacement is necessary, and if hydrostatic testing or internal maintenance is required. Section 7.3.3 states each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed, identifies the person performing the work, and identifies the name of the agency performing the work. Section 6.1.3.4 states portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means. (1) Securely on a hanger intended for the extinguishers. (2) In the bracket supplied by the extinguisher manufacture. (3) In a listed bracket approved for such purpose. (3) In a cabinet or wall recess. This deficient practice could affect all patients, as well as staff and visitors.

Findings include:

During a facility tour with the Director of Facility Management on 11/19/19 at 8:15 a.m. a fire extinguisher was located in the reception office that was past due for its annual inspection, the last recorded being in March, 2016. The extinguisher was also found unsecured on the floor. Then, at 8:26 a.m. a fire extinguisher, located in the corridor, as also past due for its annual inspection and also its six year inspection. The last recorded inspection was in March, 2010 Based on interview at the time of observation, the Director of Facility Management agreed the extinguisher were out of date.

2) Based on observation and interview, the facility failed to ensure an oxygen cylinders were maintained in accordance with NFPA 99 Health Care Facilities Code in 2 of 2 oxygen storage areas. NFPA 99, 11.3.2.3 requires oxidizing gases such as oxygen shall be separated from combustibles by one of the following: (1) a minimum distance of 20 feet. (2) a minimum distance of 5 feet if the required storage location is protected by an automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.3.2 states storage for nonflammable gases greater than 8.5 cubic meters (300 cubic feet) but less than 85 cubic meters (3000 cubic feet) shall comply with 11.3.2.1 through 11.3.2.3. NFPA 99, Section 11.3.2.6 states cylinder or container restraints shall comply with 11.6.2.3. Section 11.6.2.3(11) states freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect any patients, staff or visitors in the building.

Findings include:

During a tour of the facility with the Director of Facility Management on 11/19/19 from 8:00 a.m. to 8:45 a.m. the following conditions were found:
a) At 8:21 a.m. three unsecured compressed gas cylinders of Nitrous Oxide (1 at 1728 L) and Oxygen (2 at 682 L) were found in a dental office within five feet of a trash container and a biohazard container.
b) At 8:31 a.m. three unsecured compressed gas cylinders of oxygen (1 at 415 L, 2 at 233 L) were located in the Practice Manager's office on carpeting.
Based on interview at the time of observation, the Director of Facility Management agreed that the cylinders were unsecured and near combustibles.

Based on observation, the facility failed to ensure 1 of 3 gymnasium exits were in accordance with Chapter 7. LSC 7.1.10.2.1 requires no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof. This deficient practice could affect all occupants of the gymnasium.

Findings include:

During a facility tour with the Director of Facility Management on 11/18/19 at 3:00 p.m. the east exit door from the gymnasium, which was marked exit, was blocked by a wheeled cart. Based on interview at the time of observation, the Director of Facility Management agreed the exit was blocked.

Based on observation and interview, the facility failed to ensure 2 of 2 hazardous areas such as combustible storage rooms over 50 square feet were protected in accordance with LSC Section 19.3.2.1. Section 19.3.2.1 states that any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire-resistive rating or shall be provided with an automatic extinguishing system in accordance with Section 8.7.1. Where protected by sprinklers, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. This deficient practice could affect staff only on the second floor.

Findings include:

During a tour with the Director of Facility Management on 11/18/19 from 2:10 p.m. to 3:45 p.m. the following conditions were found:
a) At 2:26 p.m. the "Paper Storage" room had multiple cardboard boxes, stacks of paper, paper supplies, and fabric stored along the wall. The door to the room opened to the corridor and was not automatic closing.
b) At 2:34 p.m. the "Marketing Storage" room had combustible storage. The door to the room opened to the corridor and was not automatic closing.
c) At 2:37 p.m. the "Accounting Storage" room had multiple cardboard boxes, storage binders, and other paper documentation. The door to the room opened to the corridor and was not automatic closing.
Based on interview at the time of each observation, the Director of Facility Management agreed that the rooms contained combustible storage and were not properly protected.

1) Based on record review, observation and interview; the facility failed to ensure 1 of 1 kitchen fire suppression system was inspected semiannually. NFPA 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 11.2.1 states Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices. Hood exhaust plenums, and the exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at lease every six months. This deficient practice could affect staff and visitors in the kitchen.

Findings include:

During record review with the Director of Facility Management on 11/18/19 from 9:30 a.m. to 2:10 p.m. the facility provided documentation for kitchen fire suppression system inspections, however it was incomplete. The most recent documented inspection was dated on 04/04/19. The facility could not provide documentation of a subsequent inspection. Based on interview at the time of record review, the Director of Facility Management agreed that the more than six months had passed since the inspection and the kitchen hood suppression system was not inspected semi-annually. During a subsequent tour of the facility, a UL300 fire suppression system was located in the kitchen.

2) Based on record review, observation and interview; the facility failed to ensure 1 of 1 kitchen exhaust system was inspected semiannually. NFPA 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 11.4 states the entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. Table 11.4, Schedule for Inspection for Grease Buildup, requires systems serving moderate volume cooking operations shall be inspected semiannually. NFPA 96, 11.6.1 states, upon inspection, if the exhaust system is found to be contaminated with deposits from grease laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction. Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned, it shall not be coated with powder or other substance. When an exhaust cleaning service is used, a certificate showing the name of the servicing company, the name of the person performing the work, and the date of inspection or cleaning shall be maintained on the premises. This deficient practice could affect staff in the kitchen.

Findings include:

During record review with the Director of Facility Management on 11/18/19 from 9:30 a.m. to 2:10 p.m. the facility provided documentation for kitchen exhaust hood system cleaning and inspections, however it was incomplete. The most recent documented inspection was dated on 04/25/19. The facility could not provide documentation of a subsequent cleaning or inspection. Based on interview at the time of record review, the Director of Facility Management agreed that the more than six months had passed since the inspection and the kitchen exhaust hood system was not inspected semi-annually. During a subsequent tour of the facility, a UL300 exhaust hood ventilation system was located in the kitchen.

Based on observation and interview, the facility failed to maintain the ceiling construction in one area throughout the facility. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

During a tour with the Director of Facility Management on 11/18/19 at 3:20 p.m. 1 of 20 lay-in ceiling tiles was missing in Office 168. During interview at the time of observation, the Director of Facility Management acknowledged the missing ceiling tiles.

Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 2 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all residents, staff, and visitors in the facility.

Findings include:

Based on review of the quarterly sprinkler system inspection records on 11/18/19 at 12:00 p.m. with the Director of Facility Management present, there was no quarterly sprinkler system inspection report available for the first quarter (January, February, March) of 2019, or second quarter (April, May, June) of 2019. The missing quarters were confirmed by the Director of Facility Management.

1) Based on observation and interview, the facility failed to maintain 1 of 1 portable fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10. NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition, Section 5.5.5 states fire extinguishers provided for the protection of cooking appliances using combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 5.5.5.3 states a placard shall be placed near the extinguisher that states that the protection system shall be actuated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using the portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect staff in the kitchen.

Findings include:

During a tour with the Director of Facility Management on 11/18/19 at 3:08 p.m., a portable K Class fire extinguisher was located in the kitchen and a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Based on interview at the time of observation, the Director of Facility Management acknowledged a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher.

2) Based on observation and interview, the facility failed to maintain 1 of 1 Fire Extinguisher in accordance with NFPA 10, The Standard for Portable Fire Extinguishers, Section 7.2.2 which states that periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators
This deficient finding affects staff and up to 8 patients

Findings include:

During a tour of the facility with the Director of Facility Management on 11/18/19 at 3:21 p.m. a fire extinguisher was found obstructed by a refrigerator in Office 168. This was confirmed by the Director of Facility Management at the time of observation.

Based on observation and interview, the facility failed to maintain protection of 1 of 8 corridor walls in accordance of 18.3.6.2. LSC 18.3.6.2, Construction of Corridor Walls, requires corridor walls shall form a barrier to limit the transfer of smoke. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities Management on 12/07/16 at 2:34 p.m., the wall between the room and the corridor had two pass-through vents, approximately 4 inches by 8 inches in size. Based on interview at the time of observation, the Director of Facilities Management agreed the corridor wall would not limit the transfer of smoke.

Based on observation, record review, and interview the facility failed to protect 8 of 8 inpatient rooms in accordance with LSC 19.3.6.3.5 which requires that doors shall be provided with a means for keeping the door closed and withstand a force of 5 pounds. This deficient practice could have all staff and 8 inpatients in the Inpatient Care Center.

Findings include:

During a facility tour with the Director of Facility Management on 11/18/19 at 3:31 p.m. it was found that the 8 inpatient rooms of the Inpatient Care Center did not positively latch into the door frame when closed. Based on a clinical needs exception, the doors are secured with deadbolts. Based on a subsequent review of the facility "Internal Disaster Plan", the plan addressed closing doors, however did not ensure the in-patient doors, which are not positive latching, would remain closed during a fire. Based on interview at the time of observation, the Director of Facility Management agreed that the doors did not positively latch.

Based on observation and interview, the facility failed to ensure 1 of 2 sets of smoke barrier doors on the second floor would restrict the movement of smoke for at least 20 minutes. LSC, Section 19.3.7.8 requires that doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, Section 8.5.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice affects staff only on the second floor.

Findings include:

During a tour with the Director of Facility Management on 11/18/19 from 2:10 p.m. to 3:45 p.m. the second floor east smoke barrier door had been removed. Based on interview at the time of observation, the Director of Facility Management agreed that the smoke barrier door had been removed.

Based on observation and interview, the facility failed to protect 1 of 1 electrical panels in according to NFPA 70, the National Electrical Code, Article 110.26. Article 110.26 (A) states that working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code. Table 110.26(A)(1) states that minimum distance in front of electrical panels shall be 36 inches. This deficient practice could affect staff only.

Findings include:

During a tour with the Director of Facility Management on 11/18/19 at 2:32 p.m. the electrical panel in the Marketing Storage room did not have 36 inches of clearance in front of the panel. Based on interview at the time of observation, the Director of Facility Management agreed that there was not adequate clearance in front of the panel.

Based on record review, observation and interview; the facility failed to ensure 2 of 2 fire dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC) ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. Section 19.4.1.1 states the test and inspection frequency shall then be every 4 years except for hospitals where the frequency is every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff and visitors.

Findings include:

During a tour of the facility with the Director of Facility Management on 11/18/19 at 3:25 p.m. two fire dampers were located in the Cumberland Penthouse. Based on interview at the time of observation, the Director of Facility Management stated he was unaware fire dampers were in the facility. During previous record review, no documentation was provided regarding fire dampers.

Based on observation, record review, and interview, the facility failed to protect 8 of 8 inpatients in accordance with LSC 19.7.2.1.2. Section 19.7.2.1.2 requires that the response of staff shall include the following:
(3) Confinement of the effects of the fire by closing doors to isolate the fire area.
(4) Relocation of patients as detailed in the fire safety plan.
LSC 19.7.2.2 LSC requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
LSC Section 19.2.2.2.5.2 requires that (1) staff can readily unlock doors at all times.
This deficient practice affect staff and up to 8 patients in the Inpatient Care Center:

Findings include:

During a facility tour with the Director of Facility Management on 11/18/19 at 3:31 p.m. it was found that the 8 inpatient rooms of the Inpatient Care Center, were, based on a clinical needs exception, secured with deadbolts. Based on a subsequent review of the facility "Internal Disaster Plan", the plan addressed closing doors, however did not ensure the in-patient doors, which are not positive latching, would remain closed during a fire. Additionally, the plan did not address unlocking doors. This was confirmed by the Director of Facility Management at the time of observation.

1) Based on record review and interview, the facility failed to conduct 1 of 12 quarterly shift fire drills during the most recent 12 month time period. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. This deficient practice affects all staff and patients.

Findings include:

During record review with the Director of Facility Management on 11/18/19 from 9:30 a.m. to 2:10 p.m. the facility provided fire drill documentation, however it was incomplete. The facility was unable to provide documentation of a fire drill for the first and third shift for the second quarter of 2019; nor the second and third shifts for the third quarter of 2019. Based on interview at the time of record review, the Director of Facility Management acknowledged the missing fire drills.

2) Based on record review and interview, the facility failed to ensure 1 of 8 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all patients in the facility as well as staff and visitors.

Findings include:

Based on record review of titled "Emergency Drill Log" with the Director of Facility Management on 11/18/19 from 9:30 a.m. to 2:10 p.m., the fire drill for the first shift, first quarter, did not document the transmission of signal. Based on interview at the time of record review, the Director of Facility Management confirmed that the transmission of the alarm was not documented.

Based on observation and interview, the facility failed to ensure 3 of 3 offices were maintained in accordance with 19.7.5.6. LSC 19.7.5.6 prohibits combustible decorations unless an exception was met. This deficient practice could affect staff only.

Findings include:

During a tour with the Director of Facility Management on 11/18/19 from 2:10 p.m. to 3:45 p.m. the following conditions were found:
a) At 2:29 p.m. TW's office was found to have a candle with a wick.
b) At 2:56 p.m. Room 103 was found to have a candle with a wick.
c) At 2:59 p.m. TV's office was found to have a candle with a wick.
Based on interview at the time of observation, the Director of Facility Management acknowledged the aforementioned offices contained candles with wicks.

Based on observation and interview, the facility failed to ensure 3 of 3 office flexible cords were not used as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff up to 8 patients.

Findings include:

During a tour with the Director of Facility Management on 11/18/19 from 2:10 p.m. to 3:45 p.m. the following conditions were found:
a) At 3:06 p.m. a coffee maker was found powered through a surge protector in the Group Therapy Room.
b) At 3:13 p.m. a refrigerator and coffee maker were found to be powered through a surge protector in Room 117.
c) At 3:40 p.m. a coffee maker was found powered through an extension cord in Room 159.
Based on interview at the time of each observation, the Director of Facility Management agreed the cords were being used improperly.