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Based on observation, record review, and facility staff interview, the facility failed to ensure the building construction, Type II (000), was maintained. Failure to maintain the construction type puts the residents at risk in a fire by increasing the flammability of the structural frame of the building from fire. This facility had a census of 15.

1. Observations made 7/11/2023 at approximately 9:30 A.M., of the loading dock/exit ramp, showed an enclosed loading dock area measuring approximately 19 feet by 20 feet containing two bays with roll down doors. Additional observation showed the enclosed area contained a ramp with an exit door extending approximately sixty feet to the loading bays. Observation showed the enclosure had a bare red steel beam construction Type II(000) without sprinkler coverage and contained electrical service with light fixtures. Observation showed the loading dock/ramp enclosure connected to the Type II (000) hospital.

Record review of NFPA 101, Life Safety Code, 2012 edition, showed Type II (000) construction standard required full sprinkler coverage.

Record review of the facility supplied plans dated 1989 did not show an enclosure over the ramp or an enclosed loading dock.

During an interview on 7/11/2023 at approximately 10:00 A.M., the Director of Facilities said he/she did not know when the loading dock/exit ramp enclosure was built.

2. Observations made 7/12/2023 at approximately 10:20 A.M., of the IT data room near administration, did not show a sprinkler in the room.

Record review of NFPA 101, Life Safety Code, 2012 edition, showed Type II (000) construction standard required full sprinkler coverage.

During an interview on 7/12/2023 at approximately 1:50 P.M., the Director of Facilities said he/she did not know if the room ever contained a sprinkler.

Based on observation, record review and facility staff interview, facility staff failed to ensure powered doors are equipped with a self-closing device and connected to the fire alarm system. This has the potential to affect all residents, visitors and staff in the event of a fire by not limiting the passage of smoke and fire through the building structure. This facility had a census of 15.


1. Observation on 7/11/2023, during the building tour, showed the following designated exit corridor doors equipped with powered door opening devices not connected to the fire alarm system:

-Double powered doors between the kitchen and industrial hall;
-Double powered doors between the Cafe Dining room and Atrium Cafe entrance;
-Single powered door between the Cafe Dining room and Atrium Cafe entrance.

Record review of the 2022 fire alarm inspection did not show the powered cafe/kitchen doors tested with the fire alarm.

During an interview on 7/11/2023 at 10:02 A.M., the Director of Facilities stated the Cafe was renovated in 2015.


NFPA 101, 2012 edition, section 19.2.2.2.7 states:

"19.2.2.2.7* Any door in an exit passageway, stairway enclosure,
horizontal exit, smoke barrier, or hazardous area enclosure
shall be permitted to be held open only by an automatic release
device that complies with 7.2.1.8.2. The automatic sprinkler
system, if provided, and the fire alarm system, and the
systems required by 7.2.1.8.2, shall be arranged to initiate the
closing action of all such doors throughout the smoke compartment
or throughout the entire facility."

Based on observation and facility staff interview, the facility staff failed to ensure all designated exit discharge and walkway had exterior emergency egress lighting continuous to the public way. Failure to provide emergency egress lighting fixtures has the potential to affect all patients and staff within the courtyard and area served by the exit. This deficient practice could delay the safe evacuation of patients, staff and visitors in the event of an emergency. This facility had a census of 15.

1. Observation on 7/11/2023, during the building tour, showed the locked behavioral courtyard did not contain exterior light fixtures to illuminate the approximatly 190 feet travel distance from the designated exit door to the parking lot.

During an interview on 7/11/2023 at 1:08 P.M., the Director of Facilities said the sidewalk was installed in 2018 and never had lighting..

19.2.8 Illumination of Means of Egress. Means of egress shall
be illuminated in accordance with Section 7.8.


7.8.1.2 Illumination of means of egress shall be continuous
during the time that the conditions of occupancy require that
the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.

Based on observation and facility staff interview, the facility staff failed to ensure that one of one fire alarm systems was installed per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The deficient practice has the potential to effect all facility patients, staff and visitors. The deficient practice could delay fire and emergency personnel response in the event of a fire. This facility had a census of 15.

1. Observation on 7/11/2023, during the facility tour, showed the Cafe dining room and kitchen missing smoke detection. Observation showed the dining room measured approximately 3,000 square feet.

During an interview on 7/11/2023 at 10:02 A.M., the Director of Facilities stated the Cafe was renovated in 2015.

National Fire Protection Association 101, 2012 edition, section 19.3.4.1 states:

"19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6."

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and facility staff interview, the facility staff failed to provide a complete alarm notification system in one enclosed court yard. This deficient practice potentially could affect all residents, staff, and occupants in the event of a fire. This facility had a census of 15.

Observation on 7/11/2023 at 1:08 P.M., of the facility's enclosed behavioral court yard did not show audible and visual fire alarm devices.

During an interview on 7/11/23 at 1:10 P.M., the Director of Facilities stated the courtyard never had a fire alarm signaling device.

NFPA 101, 2012: Occupant Notification is provided in accordance with 9.6.3 by audible and visual signals.

Based on observation and facility staff interview, facility staff failed to ensure corridor doors had positive latching mechanisms and remained closed during activation of the fire alarm system. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure corridor doors had positive latching and powered double doors closed during activation of the fire alarm system has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. This facility had a census of 15.


1. Observation on 7/11/2023, during the building tour, showed the Central Supply room corridor entrance contained a lower half door leaf.

During an interview on 7/11/2023 at 2:45 P.M., the Director of Facilities stated the Dutch door was constructed with the building in 1992.

19.3.6.3* Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than
required enclosures of vertical openings, exits, or hazardous
areas shall be doors constructed to resist the passage of smoke
and shall be constructed of materials such as the following:
(1) 13.4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

19.3.6.3.2 The requirements of 19.3.6.3.1 shall not apply
where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink
closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required
to comply with 19.3.6.3.1.

(2) In smoke compartments protected throughout by an approved,
supervised automatic sprinkler system in accordance
with 19.3.5.7, the door construction materials requirements
of 19.3.6.3.1 shall not be mandatory, but the doors
shall be constructed to resist the passage of smoke.

19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled.

19.3.6.3.5* Doors shall be provided with a means for keeping
the door closed that is acceptable to the authority having jurisdiction,
and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully
closed if a force of 5 lbf (22 N) is applied at the latch edge
of the door.
(2) Roller latches shall be prohibited on corridor doors in
buildings not fully protected by an approved automatic
sprinkler system in accordance with 19.3.5.7.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire
Doors and Other Opening Protectives.

Based on observation, facility staff interview and record review, facility staff failed to ensure one biohazard room in the facility was adequately vented and kept under a relative negative pressure. This deficient practice has the potential to effect all residents, staff and visitors. Failure to provide adequate ventilation could increase the concentration of smoke, products of combustion and noxious fumes. This facility had a census of 15.

Observation on 7/11/23, during the facility tour, of the biohazard storage room on the loading dock area, showed the biohazard vent discharged air from inside the room to the enclosed area containing the loading dock and exit ramp.

Record review of the facility supplied building plans dated 1989 did not show an enclosure over the ramp or an enclosed loading dock.

During an interview on 7/11/2023 at approximately 10:00 A.M., the Director of Facilities said he/she did not know when the loading dock/exit ramp enclosure was built. Additionally, he/she said he/she did not know when the biohazard exhaust was installed.