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Based on observations and staff interview, the facility failed to maintain corridor doors in good working conditions with positive latching and tightness in frame, as per deigned ratings. This condition can allow for the transfer of fire, smoke, and toxic gasses from one compartment to another in the event of a fire or other emergency, endangering the patients, staff and other building occupants.

The findings include:


On November 5, 2015 from 12:45 PM to 2:45 PM while on tour with facility staff throughout the facility, it was observed multiple corridor doors from patient rooms failed to come to a tightly latched and closed position in the frame. Gaps were observed in excess of 1/8 of an inch around the door when closed in the frame, which could allow for smoke and toxic gases to enter or escape the rooms. Doors, when shut, were observed to be warped and out of alignment.

The following locations were observed but are not limited to:

614
612
609
407
404


It was acknowledged at time of finding by the Facility Maintenance Director, the door latching means were not tight in the frame and could allow for the transfer of smoke and toxic gases. Door gasket material from the manufacturer, which is fire resistant, is not present to maintain the smoke tightness of the door assembly. There shall be no impediments to the closing of the door, and latching devices with gasket fire resistant materials shall be provided, which shall keep the door tightly closed and smoke tight in the frame in accordance with NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 4.6.12.3, 4.6.12.4, 19.3.6.3, 19.7.6.


These findings were confirmed with the Facility Administrator and Facility Maintenance Director during the exit conference November 5, 2015 at 3:00 PM.

Based on observations and staff interview, the facility failed to maintain protection of hazardous areas with regard to automatic closing devices on fire rated door assemblies to maintain separation. Failure to maintain fire resistance rated separations can allow for the transfer of fire and smoke gases from one compartment to the other, endangering the patients, staff, and other building occupants.


The findings include:


1. On November 5, 2015 at 12:55 PM while on tour with facility staff in the kitchen, it was observed the dry goods storage room which utilizes a labeled 3/4 hour fire resistance-rated fire door to maintain the hazardous area room, was missing the automatic door closing mechanism. It was acknowledged by the Facility Maintenance Director at time of finding that the door closer device was missing, which does not maintain the 1-hour fire resistance-rated separation in accordance with NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 4.6.12.3, 4.6.12.4, 19.3.2.1, 19.7.6.


2. On November 5, 2015 at 1:18 PM while on tour with facility staff in the 600 Wing, Room 606 Soiled Utility Room, it was observed, a labeled 3/4 hour fire resistance-rated fire door to maintain the hazardous area room, was missing the automatic door closing mechanism. It was acknowledged by the Facility Maintenance Director at time of finding that the door closer device was missing, which does not maintain the 1-hour fire resistance-rated separation in accordance with NFPA 101 (2012) 4.5.7, 4.5.8, 4.6.12.1, 4.6.12.3, 4.6.12.4, 19.3.2.1, 19.7.6.


These findings were confirmed with the Facility Administrator and Facility Maintenance Director during the exit conference November 5, 2015 at 3:00 PM.

Based on observations and staff interview, the facility failed to provide signage indicating the location of fire extinguishers, so the locations are of a conspicuous nature and allow for quick locating of the devices, which could delay the quick extinguishment of a small fire incident and allow for the fire to grow, which can endanger the patients, staff, or other building occupants.


The findings include:


On November 5, 2015 from 12:30 PM to 2:45 PM while on tour with facility staff, it was observed throughout River Point Behavioral Health, that the fire extinguisher cabinets in use were of the slim profile and were semi-flush into the walls of the building, which can be easily obstructed or unknown as to location due to other carts or equipment when looking down corridors. It was acknowledged by the Facility Maintenance Director, at time of findings, these locations were not conspicuously designated with signage to show the immediate location of the fire extinguishers, which can delay in the locating of the closest unit in the event of a fire which is not in accordance with NFPA 10 (1998) 1-6.3, 1-6.6, 1-6.12, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.7.4.1, 19.3.5.6, 19.7.6.


These findings were confirmed with the Facility Administrator and Facility Maintenance Director during the exit conference on November 5, 2015 at 3:00 PM.