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Based on observations of the 22 Building Wings A, B, C, D, and F wings, and the McKee A building, and interview, the facility failed to ensure all doors protecting corridor openings had a suitable means for keeping them closed. This had the potential to affect all patients, staff and visitors to the facility. The census was 228 patients.

Findings include:




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a) On 08/14/13 at 10:30 A.M. a tour was conducted of the A wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
b) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
c) On 08/14/13 at 2:10 P.M. a tour was conducted of the C wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
d) On 08/14/13 at 3:13 P.M. a tour was conducted of the D wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
e) On 08/15/13 at 9:35 A.M. a tour was conducted of the F wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
In interviews during the tours, Staff C3 confirmed the observations.
f) During tour of the McKee A building on 08/14/13 between 1:08 P.M. and 2:27 P.M. , with Staff A1, B2, and E5, the following patient room corridor doors failed to latch when closed:

* Room 316 at 1:08 P.M.,
* Room 222 at 2:05 P.M.,
* Room 269 at 2:27 P.M.

This was verified with the aforementioned staff during tour.

Based on observation and interview, the facility failed to ensure each ventilation shaft was enclosed with construction having a fire resistive rating of at least one hour. This had the potential to affect all patients, staff and visitors to the facility. The census was 228 patients.

Findings include:

On 08/15/13 at 9:00 A.M. a tour of the laundry room in the E wing smoke compartment was completed with Staff C3 and Staff Y. During the tour a vertical shaft was observed going through the room.
On 08/15/13 at 9:00 A.M. in an interview during the tour, Staff Y stated the shaft opened under the building in a crawl-space like area, and opened at the roof. He/she explained it served to vent the crawl-space like area, and he/she did not know if it had any kind of damper in place to enclose it in case of fire. He/she also did not know where, exactly, the opening was in the crawl-space like area.
Review of the schematic did not reveal a rating for the vertical shaft.

Based on facility tour and staff verification it was determined this facility failed to ensure all paths of egress in which the exit access was not obvious, was equipped with exit and directional signs displayed in accordance with the National Fire Protection Association 101, Chapter 19 and Chapter 7. This involved the first floor of the McKee Building and one exit in the 22 Building. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 228.

Findings include:

On 08/14/13 through 08/15/13, main building facility tour took place with staff members A1 and B2. During tour on the first floor in the McKee A building, on 08/14/13 between 3:22 P.M. and 4:40 P.M., exit signs were visible as follows:
a) The pharmacy was observed with three rooms and large shelves used for medication storage. The shelves were located the larger of the three rooms, and impeded staff from being able to visualize the front door. The pharmacy lacked a visible exit sign.
b) The Human Resources Office contained multiple offices, an open reception area, and a hallway where additional rooms were located. Two exit access doors were observed leading to the corridor from this suite of rooms; however, only one of the two doors contained a visible exit sign. An exit sign inside the suite was observed located in the hallway which contained offices and a reception room. The sign lacked directional indicators for the flow of exit.
c) Between the McKee A and B buildings on the first floor, a connector vestibule was observed with two exit doors with an illuminated exit sign above the doors. One exit led to the sidewalk leading to the main entrance. The second exit was observed with glass doors and a glass panel on each side of the exit doors. All four glass panels (including the 2 exit doors) were observed each with a sign stating courtyard closed until 2:00 PM. When questioned as to whether the courtyard was closed to exit traffic, Staff B2 stated the courtyard was not closed to exit traffic. Staff B2 was observed removing the paper exit signs, stating they should not have been placed on the doors.
d) The McKee B building was observed with an exit access door which contained an illuminated exit sign above the door. This access door led to a solarium which was observed with numerous chairs and a mobile cart. The exit discharge door lacked an exit sign, and was blocked with chairs and the mobile cart. This was verified with Staff A1 at the time of tour. A glass door leading to a patio was observed with a paper sign stating exit. The patio was enclosed with a brick wall approximately 3 feet high, and lacked a means of exit from the patio. Staff B1 removed the paper exit sign, stating this was not a designated exit.
This finding was verified by all staff members present during tour of this area.





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e) On 08/14/13 at 4:05 P.M. a tour was conducted of the activities room with Staff C3. Observation of exit from door G185-2 revealed the exit sign on the left path of egress was not readily visible.
During the tour, Staff C3 confirmed the observation.

Based on observations and staff interviews, the facility failed to ensure two smoke barriers were constructed to provide at lease a one half hour fire resistance rating in accordance with 8.2. This involved one area in the McKee A building and one area in the 22 Building. This could potentially affect all patients in the facility. The census on the first survey day was 228 patients.

Findings include:

a) On 08/14/13 at 2:20 P.M., a tour, conducted with Staff A1, B2, and E5, of the second floor team conference room 240 was observed with approximately an eight by eight inch diameter opening in one side of the drywall in the smoke barrier. This was confirmed with Staff B2 during tour.


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In the 22 Building:
b) On 08/14/13 at 4:05 P.M. the smoke barrier separating the E wing from corridor G153 was observed to contain a penetration approximately one half foot high by one foot wide.
c) On 08/14/13 at 4:05 P.M. in an interview, Staff Y confirmed the observation.

Based on observations and staff interviews, the facility failed to ensure three sets of smoke barrier doors closed with released from the automatic hold open device, and failed to perform preventative maintenance on the doors to ensure proper closure. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 228.

Findings include:

On 08/14/13 through 08/15/13, the McKee A building tour took place with staff members A1, B2, and E5. During tour, the following smoke barrier doors failed to close when released from the automatic hold open device:

a) Tour of the fourth floor revealed smoke barrier doors by room 410 did not close when tested on 08/14/13 at 11:18 A.M.


b) On 08/14/13, tour of the third floor revealed smoke barrier doors by room 309 failed to close when tested at 1:17 P.M. Another set of smoke barrier doors on this floor failed to close by room 351 at 1:40 P.M.

When questioned during this tour regarding a preventative maintenance program to check these doors for closure, Staff A1 and E5 responded there used to be a program; however, there is no current preventative maintenance program to check the smoke barrier doors.

Based observations and staff interviews, the facility contained 2 delayed egress locked doors in the path of egress in the McKee Building, and up to 4 delayed egress locked doors in the path of egress in the 22 Building. Two exit discharges in the McKee building lacked a paved hard surface to the public way. One exit discharge in the McKee building was observed blocked with chairs and a cart. One staff member was unaware of having a key to unlock an exit access stairwell door on one floor of the McKee building. This could affect all patients, staff, and visitors in the facility. The census on the first survey day was 228 patients.

Findings include:

On 08/14/13, between 10:00 A.M. and 4:40 P.M., a tour was conducted in the McKee building with Staff A1 and B2.
a) On the fourth floor in-patient unit of this building, during this tour at 10:58 A.M., the Northeast Stairwell door was observed locked and alarmed. The surveyor asked a housekeeping employee (Staff D4) to use their key to unlock the stairwell door. This employee stated they did not have a key. Staff B2 informed employee D4 that all staff have a key to unlock egress doors, as did this employee (Staff D4). Staff B2 took Staff D4's keys and found the key for the egress doors. Staff D4 then proceeded to unlock the stairwell door. An interview with Staff D4 at that time revealed this employee had worked in this facility for several years.
b) On 08/15/13, at 9:15 A.M., the McKee B building was observed with an exit access door which contained an illuminated exit sign above the door. This access door led to a solarium which was observed with numerous chairs, a table, and a mobile supply cart. The exit discharge door was observed blocked with chairs and a mobile cart. This was verified with Staff A1 at the time of tour.
c) During this visit, on 08/14/13 between 8:30 A.M. and 4:45 P.M., and on 08/15/13 between 8:30 A.M. and 12:00 P.M., the facility was observed with 2 delayed locked egress doors in the path of exit. These doors were kept locked and were observed opening only with a key carried by staff. The second, third, and fourth floors in the McKee in-patient unit was observed with two stairwell doors (Northeast and Southeast) which required a key to open the doors. After entering the stairwells, an exit discharge door was observed located on the landing between floors 1 and 2. These exit discharge doors also required a key to unlock the doors in order to exit the building.
Upon opening the Northeast and Southeast stairwell exit doors, observation of the path of egress to the public way revealed a concrete pad outside each exit door from the stairwell. The concrete ended approximately 5 feet from the exit discharge doors. Construction was being done of the area outside these exit doors, which revealed a large graded dirt area approximately a football field in length (at long as the building) and required travel across the dirt approximately 150-200 feet in order to reach a paved surface.
d) The exit discharge doors on the south side of the building between McKee Building A and B, which exited into the courtyard, also required a key to unlock the doors. Once entering the courtyard, two exit doors also required use of a key to unlock the doors, in order to exit the building an courtyard.
These exits were verified with Staff A1 and B2 during tour. Staff E5 was also present during tour of the stairwell towers and exit discharges, and verified the delayed egress locks and path of travel outside the exit discharges.






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In the 22 Building:
e) On 08/14/13 at 10:30 A.M. a tour was conducted of the A wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
f) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
g) On 08/14/13 at 2:10 P.M. a tour was conducted of the C wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
h) On 08/14/13 at 3:13 P.M. a tour was conducted of the D wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
i) On 08/15/13 at 9:00 A.M. a tour was conducted of the E wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
j) On 08/15/13 at 9:35 A.M. a tour was conducted of the F wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
The observations were confirmed by Staff C3 in interviews during the tours.

Based on observations and staff interviews, the facility failed to ensure three exit discharges were illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness in accordance with the code at 7.8.1.4. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 228.

Findings include:


Tour was conducted on the first floor on 08/14/13 between 2:35 P.M. and 4:40 P.M. with Staff A1 and B2. During this tour, the following designated exit discharges were observed with either one light or none at the exit discharge.

These exits are as follows:

a) The exit discharge from the northeast and southeast stairwells were observed with only one source of light at the exit discharge.

b)The exit discharge from the dock on the south side of the building was observed with only one light at the exit discharge.

c) The south exit from the courtyard was observed with one discharge light outside the exit door, which was located in a brick wall that enclosed the courtyard. The exit path to the public way, from the courtyard was approximately 35 feet in length with a ninety-degree turn in the sidewalk. The pathway lacked exit discharge lighting.

The lack of exit discharge lighting was verified during tour with Staff A1 and B2.

Based on observations during tour, and staff interviews, the facility failed to ensure NPFA 101, 9.6.1.4, and NFPA 72, 2-3.5 were followed in regard to smoke detector placement in spaces served by air-handling systems. The facility failed to ensure smoke detectors were not located less than 36 inches from air flow supply or return vents in places where airflow patterns could prevent the normal operation of the detectors. This could affect all patients, staff, and visitors in the facility. The total patient census on the first survey day was 228.

Findings include:


On 08/14/13, between 10:00 A.M. and 4:40 P.M., and on 08/15/13 between 8:30 A.M. and 12:00 P.M., a tour was conducted in the McKee building with Staff A1 and B2. Staff E4 was present during a portion of the tour on 08/14/13. Smoke detectors were observed located throughout the facility less than 36 inches from air supply and/or air return diffusers as follows:

Inside McKee A building
On the fourth floor
a) inside the Sallyport by the elevators

On the third floor
b) by the conference room located by multipurpose room 303

On the second floor
c) inside the bathroom (room 205) inside the seclusion room 206

Inside McKee B building
On the first floor
d) inside the IT office room B128

Inside the connector between McKee A and C buildings
e) in the connector near the 2 hour fire wall for A building.

These smoke detector locations were verified with the aforementioned staff during tour.

An interview was conducted with Staff C3, on 08/15/13 at 1:57 P.M., regarding manufacturers specifications in regards to location of these smoke detectors. Staff C3 provided this information, and verified the manufacturer's information stated the smoke detectors shall be located in accordance with NFPA 72.

Based on observations, fire alarm inspection reports, and staff interview, the facility failed to maintain documentation of sensitivity testing of the smoke detectors, in accordance with the code at 9.6.1.4 and in accordance with NFPA 72. This could affect all patients, staff, and visitors in the facility. The total patient census on the first survey day was 228.


Findings include:


On 08/14/13, between 10:00 A.M. and 4:40 P.M., a tour was conducted in the McKee building with Staff A1 and B2. Staff E4 was present during a portion of the tour on 08/14/13. Smoke detectors were observed located throughout the facility. According to Staff A1, these smoke detectors were connected to the fire alarm system.

On 08/15/13, a review of the fire alarm inspections revealed a lack of documentation of smoke detector sensitivity testing.

An interview was conducted with Staff C3, on 08/15/13 at 1:57 P.M., regarding sensitivity testing of these smoke detectors. Staff C3 was then observed phoning the outside fire alarm service company to inquire if sensitivity testing had been conducted. After the phone call concluded, Staff C3 stated the facility is equipped with a self-diagnostic fire alarm system, and verified there was no printed sensitivity report on the smoke detectors.

Based on observation and interview, the facility failed to ensure the sprinkler riser room in Building 22 contained the necessary spare amount of the type and kind of sprinkler heads used in the building and the wrenches necessary to install each type and kind of sprinkler head used in the building. This could affect all patients in the facility. The total census of patients on the first survey day was 228.

Findings include:

The lack of sprinkler heads in the 22 Building was identified in inspection reports by an outside service company on 07/30/13 and 09/13/12. Staff A1 and E5 were made aware of this these inspection reports on 08/15/13 at 4:00 P.M.


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On 08/14/13 at 3:05 P.M. the sprinkler riser room for Building 22 was toured with Staff C3 and Y. During the tour, neither a sprinkler wrench for each type of sprinkler installed nor any spare sprinklers (a minimum of two or a representative sample) of the type and kind of sprinkler installed were observed.
On 08/14/13 at 3:05 P.M. in an interview, C3 confirmed the observation.

Based upon observation of the B wing, and interview, the facility failed to ensure compliance with Life Safety Code 101, 2000 edition, and NFPA 90A. This had the potential to affect all patients, staff and visitors to the facility. The census on the first survey day was 228 patients.

Findings include:

a) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. The B wing was observed to be sprinklered throughout with smoke detection in the corridor. Observation above the drop down ceiling revealed air flowing and a heating, ventilation and cooling duct system.
b) On 08/14/13 at 2:00 P.M. in an interview Staff Y stated the wing has its own air supply handler located on the roof. He/she explained each room (and not the hallway) had a return air vent.
c) Observation of the return air vents revealed in patient rooms B130 and B125 there wasn't a strong return of air in the vents in the room. This was evidenced by the return air vent being unable to hold tissue paper. This had the effect of the heating, ventilation and cooling system pumping air into the patients' rooms without a provision for exhausting it out and the air can only then flow out into the corridor from the room.
d) On 08/14/13 at 2:00 P.M. in an interview Staff Y stated probably the whole wing was affected and there was mechanical failure with the return air system.

Based on observations and staff interviews, the facility failed to ensure portable space heating devices were not used in patient sleeping areas, and lacked information these devices used in offices did not exceed 212 degrees Fahrenheit (F). This involved patient sleeping areas in the 22 Building and offices in McKee A building. This could affect all patients in the facility. The census on the first survey day was 228 patients.
Findings include:


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a) On 08/14/13 at 10:30 A.M. a tour was conducted of the A wing with Staff C3 and Y. In room A128, a staff office-situated among patient sleeping rooms--a space heater was found.
b) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. In room B128, a staff office-situated among patient sleeping rooms--a space heater was found.
c) On 08/14/13 at 3:13 P.M. a tour was conducted of the D wing with Staff C3 and Y. In room D126, a staff office-situated among patient sleeping rooms--a space heater was found unattended and running on the low setting. In room D127, a staff office-situated among patient sleeping rooms--a space heater was found.
d) On 08/15/13 at 9:00 A.M. a tour was conducted of the E wing with Staff C3 and Y. In room E127, a staff office-situated among patient sleeping rooms--a space heater was found running on the low setting unattended.
e) On 08/15/13 at 9:35 A.M. a tour was conducted of the F wing with Staff C3 and Y. In room F127, a staff office-situated among patient sleeping rooms--a space heater was found. In room E101A a space heater was found, and in room E101B a large space heater, about three feet high, was also found. Rooms E101A and E101B are used as offices and share the same smoke compartment in the F wing as the patient rooms.
f) On 08/14/13 between 3:40 P.M. and 3:45 P.M., two space heaters were observed in two different offices in the Human Resources office suite located on the first floor of McKee A building. This was verified with Staff A1 during tour. When asked if Staff A1 was aware of the maximum temperature of the space heaters, this staff member stated they did not know, and was unaware the space heaters were in the building.

In interviews during the tours, Staff C3 confirmed the observations.

Based on interview and generator inspection reports, the facility failed to ensure the generator was inspected weekly, and failed to ensure the generator transferred power within 10 seconds during testing, in accordance with NFPA 99, 3-4.1.1.8. This could affect all patients in the facility. The total census on the first survey day was 228.


Findings include:


On 08/15/13, a review was conducted of the generator testing and maintenance logs. An interview was conducted with Staff B2 between 2:30 P.M. and 3:00 P.M. that same day regarding the generator logs.
These logs were reviewed from November 2010 through July 2013. The logs revealed two generators which supplied emergency power to the inpatient units of McKee Building and 22 Building. According to these logs, both generators exceeded 10 seconds from activation of the automatic transfer switch to start-up of the generator in November and December 2012, and January through July 2013, except April 2013 and July 2013. The transfer switch time was listed as 30 seconds for these months. The McKee building log also failed to document the percent of load that was tested on 12/19/12. The 22 Building log was silent to the percent of load that was tested on 07/18/13. These generator logs documented repairs needed for power failure to transfer of 30 seconds on each of the aforementioned months the testing exceeded 10 seconds.

These generator testing logs were silent to weekly inspections between November 2012
and August 2013. On 08/15/13 at 3:00 P.M., Staff B2 verified the lack of weekly generator inspections, the time frames of 30 seconds for transfer of power, and the lack of documentation of the percent of load that was tested. This employee stated the testing was completed by an outside service person and verified there was no action plan to correct the 30 second delay for the automatic transfer switch.

Based on observations on the 22 Building B, D, E, and F wings, and interview, the facility failed to ensure compliance with NFPA 70 by daisy chaining power strips. This had the potential to affect all patients, staff and visitors to the facility. The census was 228 patients.

Findings include:

a) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. At the nursing station a square power brick with four receptacles was observed to be plugged into a power strip with four receptacles, which in turn was plugged into the wall receptacle.
b) On 08/14/13 at 3:13 P.M. a tour was conducted of the D wing with Staff C3 and Y. Observation of the break room area revealed a power strip with two of seven receptacles in use plugged into a power strip with three of four receptacles in use that was then plugged into the wall receptacle.
c) On 08/15/13 at 9:00 A.M. a tour was conducted of the E wing with Staff C3 and Y. Observation of the break room area revealed a power strip with four of six receptacles in use plugged into a power strip with four of five receptacles in use that was plugged into the wall receptacle.
d) On 08/15/13 at 9:35 A.M. a tour was conducted of the F wing with Staff C3 and Y. Observation of the break room area revealed a power strip with two of six receptacles in use plugged into a power strip with three of four receptacles in use that was plugged into the wall receptacle.
In interviews during the tours, Staff C3 confirmed the observations.

Based on observations of the 22 Building Wings A, B, C, D, and F wings, and the McKee A building, and interview, the facility failed to ensure all doors protecting corridor openings had a suitable means for keeping them closed. This had the potential to affect all patients, staff and visitors to the facility. The census was 228 patients.

Findings include:




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a) On 08/14/13 at 10:30 A.M. a tour was conducted of the A wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
b) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
c) On 08/14/13 at 2:10 P.M. a tour was conducted of the C wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
d) On 08/14/13 at 3:13 P.M. a tour was conducted of the D wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
e) On 08/15/13 at 9:35 A.M. a tour was conducted of the F wing with Staff C3 and Y. Observation of the door from the seclusion room onto the corridor revealed the door did not have a means suitable for keeping it closed.
In interviews during the tours, Staff C3 confirmed the observations.
f) During tour of the McKee A building on 08/14/13 between 1:08 P.M. and 2:27 P.M. , with Staff A1, B2, and E5, the following patient room corridor doors failed to latch when closed:

* Room 316 at 1:08 P.M.,
* Room 222 at 2:05 P.M.,
* Room 269 at 2:27 P.M.

This was verified with the aforementioned staff during tour.

Based on observation and interview, the facility failed to ensure each ventilation shaft was enclosed with construction having a fire resistive rating of at least one hour. This had the potential to affect all patients, staff and visitors to the facility. The census was 228 patients.

Findings include:

On 08/15/13 at 9:00 A.M. a tour of the laundry room in the E wing smoke compartment was completed with Staff C3 and Staff Y. During the tour a vertical shaft was observed going through the room.
On 08/15/13 at 9:00 A.M. in an interview during the tour, Staff Y stated the shaft opened under the building in a crawl-space like area, and opened at the roof. He/she explained it served to vent the crawl-space like area, and he/she did not know if it had any kind of damper in place to enclose it in case of fire. He/she also did not know where, exactly, the opening was in the crawl-space like area.
Review of the schematic did not reveal a rating for the vertical shaft.

Based on facility tour and staff verification it was determined this facility failed to ensure all paths of egress in which the exit access was not obvious, was equipped with exit and directional signs displayed in accordance with the National Fire Protection Association 101, Chapter 19 and Chapter 7. This involved the first floor of the McKee Building and one exit in the 22 Building. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 228.

Findings include:

On 08/14/13 through 08/15/13, main building facility tour took place with staff members A1 and B2. During tour on the first floor in the McKee A building, on 08/14/13 between 3:22 P.M. and 4:40 P.M., exit signs were visible as follows:
a) The pharmacy was observed with three rooms and large shelves used for medication storage. The shelves were located the larger of the three rooms, and impeded staff from being able to visualize the front door. The pharmacy lacked a visible exit sign.
b) The Human Resources Office contained multiple offices, an open reception area, and a hallway where additional rooms were located. Two exit access doors were observed leading to the corridor from this suite of rooms; however, only one of the two doors contained a visible exit sign. An exit sign inside the suite was observed located in the hallway which contained offices and a reception room. The sign lacked directional indicators for the flow of exit.
c) Between the McKee A and B buildings on the first floor, a connector vestibule was observed with two exit doors with an illuminated exit sign above the doors. One exit led to the sidewalk leading to the main entrance. The second exit was observed with glass doors and a glass panel on each side of the exit doors. All four glass panels (including the 2 exit doors) were observed each with a sign stating courtyard closed until 2:00 PM. When questioned as to whether the courtyard was closed to exit traffic, Staff B2 stated the courtyard was not closed to exit traffic. Staff B2 was observed removing the paper exit signs, stating they should not have been placed on the doors.
d) The McKee B building was observed with an exit access door which contained an illuminated exit sign above the door. This access door led to a solarium which was observed with numerous chairs and a mobile cart. The exit discharge door lacked an exit sign, and was blocked with chairs and the mobile cart. This was verified with Staff A1 at the time of tour. A glass door leading to a patio was observed with a paper sign stating exit. The patio was enclosed with a brick wall approximately 3 feet high, and lacked a means of exit from the patio. Staff B1 removed the paper exit sign, stating this was not a designated exit.
This finding was verified by all staff members present during tour of this area.





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e) On 08/14/13 at 4:05 P.M. a tour was conducted of the activities room with Staff C3. Observation of exit from door G185-2 revealed the exit sign on the left path of egress was not readily visible.
During the tour, Staff C3 confirmed the observation.

Based on observations and staff interviews, the facility failed to ensure two smoke barriers were constructed to provide at lease a one half hour fire resistance rating in accordance with 8.2. This involved one area in the McKee A building and one area in the 22 Building. This could potentially affect all patients in the facility. The census on the first survey day was 228 patients.

Findings include:

a) On 08/14/13 at 2:20 P.M., a tour, conducted with Staff A1, B2, and E5, of the second floor team conference room 240 was observed with approximately an eight by eight inch diameter opening in one side of the drywall in the smoke barrier. This was confirmed with Staff B2 during tour.


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In the 22 Building:
b) On 08/14/13 at 4:05 P.M. the smoke barrier separating the E wing from corridor G153 was observed to contain a penetration approximately one half foot high by one foot wide.
c) On 08/14/13 at 4:05 P.M. in an interview, Staff Y confirmed the observation.

Based on observations and staff interviews, the facility failed to ensure three sets of smoke barrier doors closed with released from the automatic hold open device, and failed to perform preventative maintenance on the doors to ensure proper closure. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 228.

Findings include:

On 08/14/13 through 08/15/13, the McKee A building tour took place with staff members A1, B2, and E5. During tour, the following smoke barrier doors failed to close when released from the automatic hold open device:

a) Tour of the fourth floor revealed smoke barrier doors by room 410 did not close when tested on 08/14/13 at 11:18 A.M.


b) On 08/14/13, tour of the third floor revealed smoke barrier doors by room 309 failed to close when tested at 1:17 P.M. Another set of smoke barrier doors on this floor failed to close by room 351 at 1:40 P.M.

When questioned during this tour regarding a preventative maintenance program to check these doors for closure, Staff A1 and E5 responded there used to be a program; however, there is no current preventative maintenance program to check the smoke barrier doors.

Based observations and staff interviews, the facility contained 2 delayed egress locked doors in the path of egress in the McKee Building, and up to 4 delayed egress locked doors in the path of egress in the 22 Building. Two exit discharges in the McKee building lacked a paved hard surface to the public way. One exit discharge in the McKee building was observed blocked with chairs and a cart. One staff member was unaware of having a key to unlock an exit access stairwell door on one floor of the McKee building. This could affect all patients, staff, and visitors in the facility. The census on the first survey day was 228 patients.

Findings include:

On 08/14/13, between 10:00 A.M. and 4:40 P.M., a tour was conducted in the McKee building with Staff A1 and B2.
a) On the fourth floor in-patient unit of this building, during this tour at 10:58 A.M., the Northeast Stairwell door was observed locked and alarmed. The surveyor asked a housekeeping employee (Staff D4) to use their key to unlock the stairwell door. This employee stated they did not have a key. Staff B2 informed employee D4 that all staff have a key to unlock egress doors, as did this employee (Staff D4). Staff B2 took Staff D4's keys and found the key for the egress doors. Staff D4 then proceeded to unlock the stairwell door. An interview with Staff D4 at that time revealed this employee had worked in this facility for several years.
b) On 08/15/13, at 9:15 A.M., the McKee B building was observed with an exit access door which contained an illuminated exit sign above the door. This access door led to a solarium which was observed with numerous chairs, a table, and a mobile supply cart. The exit discharge door was observed blocked with chairs and a mobile cart. This was verified with Staff A1 at the time of tour.
c) During this visit, on 08/14/13 between 8:30 A.M. and 4:45 P.M., and on 08/15/13 between 8:30 A.M. and 12:00 P.M., the facility was observed with 2 delayed locked egress doors in the path of exit. These doors were kept locked and were observed opening only with a key carried by staff. The second, third, and fourth floors in the McKee in-patient unit was observed with two stairwell doors (Northeast and Southeast) which required a key to open the doors. After entering the stairwells, an exit discharge door was observed located on the landing between floors 1 and 2. These exit discharge doors also required a key to unlock the doors in order to exit the building.
Upon opening the Northeast and Southeast stairwell exit doors, observation of the path of egress to the public way revealed a concrete pad outside each exit door from the stairwell. The concrete ended approximately 5 feet from the exit discharge doors. Construction was being done of the area outside these exit doors, which revealed a large graded dirt area approximately a football field in length (at long as the building) and required travel across the dirt approximately 150-200 feet in order to reach a paved surface.
d) The exit discharge doors on the south side of the building between McKee Building A and B, which exited into the courtyard, also required a key to unlock the doors. Once entering the courtyard, two exit doors also required use of a key to unlock the doors, in order to exit the building an courtyard.
These exits were verified with Staff A1 and B2 during tour. Staff E5 was also present during tour of the stairwell towers and exit discharges, and verified the delayed egress locks and path of travel outside the exit discharges.






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In the 22 Building:
e) On 08/14/13 at 10:30 A.M. a tour was conducted of the A wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
f) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
g) On 08/14/13 at 2:10 P.M. a tour was conducted of the C wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
h) On 08/14/13 at 3:13 P.M. a tour was conducted of the D wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
i) On 08/15/13 at 9:00 A.M. a tour was conducted of the E wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
j) On 08/15/13 at 9:35 A.M. a tour was conducted of the F wing with Staff C3 and Y. During the tour the wing was observed to have two sally ports: one at the entrance from the corridor, and another at the day hall which lead to the outside. Each sally port was observed on a path of egress, and each was observed to require the use of a key to unlock each door within the sally ports themselves. (Activation of the fire alarm did not release the locks on these doors.)
The observations were confirmed by Staff C3 in interviews during the tours.

Based on observations and staff interviews, the facility failed to ensure three exit discharges were illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness in accordance with the code at 7.8.1.4. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 228.

Findings include:


Tour was conducted on the first floor on 08/14/13 between 2:35 P.M. and 4:40 P.M. with Staff A1 and B2. During this tour, the following designated exit discharges were observed with either one light or none at the exit discharge.

These exits are as follows:

a) The exit discharge from the northeast and southeast stairwells were observed with only one source of light at the exit discharge.

b)The exit discharge from the dock on the south side of the building was observed with only one light at the exit discharge.

c) The south exit from the courtyard was observed with one discharge light outside the exit door, which was located in a brick wall that enclosed the courtyard. The exit path to the public way, from the courtyard was approximately 35 feet in length with a ninety-degree turn in the sidewalk. The pathway lacked exit discharge lighting.

The lack of exit discharge lighting was verified during tour with Staff A1 and B2.

Based on observations during tour, and staff interviews, the facility failed to ensure NPFA 101, 9.6.1.4, and NFPA 72, 2-3.5 were followed in regard to smoke detector placement in spaces served by air-handling systems. The facility failed to ensure smoke detectors were not located less than 36 inches from air flow supply or return vents in places where airflow patterns could prevent the normal operation of the detectors. This could affect all patients, staff, and visitors in the facility. The total patient census on the first survey day was 228.

Findings include:


On 08/14/13, between 10:00 A.M. and 4:40 P.M., and on 08/15/13 between 8:30 A.M. and 12:00 P.M., a tour was conducted in the McKee building with Staff A1 and B2. Staff E4 was present during a portion of the tour on 08/14/13. Smoke detectors were observed located throughout the facility less than 36 inches from air supply and/or air return diffusers as follows:

Inside McKee A building
On the fourth floor
a) inside the Sallyport by the elevators

On the third floor
b) by the conference room located by multipurpose room 303

On the second floor
c) inside the bathroom (room 205) inside the seclusion room 206

Inside McKee B building
On the first floor
d) inside the IT office room B128

Inside the connector between McKee A and C buildings
e) in the connector near the 2 hour fire wall for A building.

These smoke detector locations were verified with the aforementioned staff during tour.

An interview was conducted with Staff C3, on 08/15/13 at 1:57 P.M., regarding manufacturers specifications in regards to location of these smoke detectors. Staff C3 provided this information, and verified the manufacturer's information stated the smoke detectors shall be located in accordance with NFPA 72.

Based on observations, fire alarm inspection reports, and staff interview, the facility failed to maintain documentation of sensitivity testing of the smoke detectors, in accordance with the code at 9.6.1.4 and in accordance with NFPA 72. This could affect all patients, staff, and visitors in the facility. The total patient census on the first survey day was 228.


Findings include:


On 08/14/13, between 10:00 A.M. and 4:40 P.M., a tour was conducted in the McKee building with Staff A1 and B2. Staff E4 was present during a portion of the tour on 08/14/13. Smoke detectors were observed located throughout the facility. According to Staff A1, these smoke detectors were connected to the fire alarm system.

On 08/15/13, a review of the fire alarm inspections revealed a lack of documentation of smoke detector sensitivity testing.

An interview was conducted with Staff C3, on 08/15/13 at 1:57 P.M., regarding sensitivity testing of these smoke detectors. Staff C3 was then observed phoning the outside fire alarm service company to inquire if sensitivity testing had been conducted. After the phone call concluded, Staff C3 stated the facility is equipped with a self-diagnostic fire alarm system, and verified there was no printed sensitivity report on the smoke detectors.

Based on observation and interview, the facility failed to ensure the sprinkler riser room in Building 22 contained the necessary spare amount of the type and kind of sprinkler heads used in the building and the wrenches necessary to install each type and kind of sprinkler head used in the building. This could affect all patients in the facility. The total census of patients on the first survey day was 228.

Findings include:

The lack of sprinkler heads in the 22 Building was identified in inspection reports by an outside service company on 07/30/13 and 09/13/12. Staff A1 and E5 were made aware of this these inspection reports on 08/15/13 at 4:00 P.M.


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On 08/14/13 at 3:05 P.M. the sprinkler riser room for Building 22 was toured with Staff C3 and Y. During the tour, neither a sprinkler wrench for each type of sprinkler installed nor any spare sprinklers (a minimum of two or a representative sample) of the type and kind of sprinkler installed were observed.
On 08/14/13 at 3:05 P.M. in an interview, C3 confirmed the observation.

Based upon observation of the B wing, and interview, the facility failed to ensure compliance with Life Safety Code 101, 2000 edition, and NFPA 90A. This had the potential to affect all patients, staff and visitors to the facility. The census on the first survey day was 228 patients.

Findings include:

a) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. The B wing was observed to be sprinklered throughout with smoke detection in the corridor. Observation above the drop down ceiling revealed air flowing and a heating, ventilation and cooling duct system.
b) On 08/14/13 at 2:00 P.M. in an interview Staff Y stated the wing has its own air supply handler located on the roof. He/she explained each room (and not the hallway) had a return air vent.
c) Observation of the return air vents revealed in patient rooms B130 and B125 there wasn't a strong return of air in the vents in the room. This was evidenced by the return air vent being unable to hold tissue paper. This had the effect of the heating, ventilation and cooling system pumping air into the patients' rooms without a provision for exhausting it out and the air can only then flow out into the corridor from the room.
d) On 08/14/13 at 2:00 P.M. in an interview Staff Y stated probably the whole wing was affected and there was mechanical failure with the return air system.

Based on observations and staff interviews, the facility failed to ensure portable space heating devices were not used in patient sleeping areas, and lacked information these devices used in offices did not exceed 212 degrees Fahrenheit (F). This involved patient sleeping areas in the 22 Building and offices in McKee A building. This could affect all patients in the facility. The census on the first survey day was 228 patients.
Findings include:


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a) On 08/14/13 at 10:30 A.M. a tour was conducted of the A wing with Staff C3 and Y. In room A128, a staff office-situated among patient sleeping rooms--a space heater was found.
b) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. In room B128, a staff office-situated among patient sleeping rooms--a space heater was found.
c) On 08/14/13 at 3:13 P.M. a tour was conducted of the D wing with Staff C3 and Y. In room D126, a staff office-situated among patient sleeping rooms--a space heater was found unattended and running on the low setting. In room D127, a staff office-situated among patient sleeping rooms--a space heater was found.
d) On 08/15/13 at 9:00 A.M. a tour was conducted of the E wing with Staff C3 and Y. In room E127, a staff office-situated among patient sleeping rooms--a space heater was found running on the low setting unattended.
e) On 08/15/13 at 9:35 A.M. a tour was conducted of the F wing with Staff C3 and Y. In room F127, a staff office-situated among patient sleeping rooms--a space heater was found. In room E101A a space heater was found, and in room E101B a large space heater, about three feet high, was also found. Rooms E101A and E101B are used as offices and share the same smoke compartment in the F wing as the patient rooms.
f) On 08/14/13 between 3:40 P.M. and 3:45 P.M., two space heaters were observed in two different offices in the Human Resources office suite located on the first floor of McKee A building. This was verified with Staff A1 during tour. When asked if Staff A1 was aware of the maximum temperature of the space heaters, this staff member stated they did not know, and was unaware the space heaters were in the building.

In interviews during the tours, Staff C3 confirmed the observations.

Based on interview and generator inspection reports, the facility failed to ensure the generator was inspected weekly, and failed to ensure the generator transferred power within 10 seconds during testing, in accordance with NFPA 99, 3-4.1.1.8. This could affect all patients in the facility. The total census on the first survey day was 228.


Findings include:


On 08/15/13, a review was conducted of the generator testing and maintenance logs. An interview was conducted with Staff B2 between 2:30 P.M. and 3:00 P.M. that same day regarding the generator logs.
These logs were reviewed from November 2010 through July 2013. The logs revealed two generators which supplied emergency power to the inpatient units of McKee Building and 22 Building. According to these logs, both generators exceeded 10 seconds from activation of the automatic transfer switch to start-up of the generator in November and December 2012, and January through July 2013, except April 2013 and July 2013. The transfer switch time was listed as 30 seconds for these months. The McKee building log also failed to document the percent of load that was tested on 12/19/12. The 22 Building log was silent to the percent of load that was tested on 07/18/13. These generator logs documented repairs needed for power failure to transfer of 30 seconds on each of the aforementioned months the testing exceeded 10 seconds.

These generator testing logs were silent to weekly inspections between November 2012
and August 2013. On 08/15/13 at 3:00 P.M., Staff B2 verified the lack of weekly generator inspections, the time frames of 30 seconds for transfer of power, and the lack of documentation of the percent of load that was tested. This employee stated the testing was completed by an outside service person and verified there was no action plan to correct the 30 second delay for the automatic transfer switch.

Based on observations on the 22 Building B, D, E, and F wings, and interview, the facility failed to ensure compliance with NFPA 70 by daisy chaining power strips. This had the potential to affect all patients, staff and visitors to the facility. The census was 228 patients.

Findings include:

a) On 08/14/13 at 11:25 A.M. a tour was conducted of the B wing with Staff C3 and Y. At the nursing station a square power brick with four receptacles was observed to be plugged into a power strip with four receptacles, which in turn was plugged into the wall receptacle.
b) On 08/14/13 at 3:13 P.M. a tour was conducted of the D wing with Staff C3 and Y. Observation of the break room area revealed a power strip with two of seven receptacles in use plugged into a power strip with three of four receptacles in use that was then plugged into the wall receptacle.
c) On 08/15/13 at 9:00 A.M. a tour was conducted of the E wing with Staff C3 and Y. Observation of the break room area revealed a power strip with four of six receptacles in use plugged into a power strip with four of five receptacles in use that was plugged into the wall receptacle.
d) On 08/15/13 at 9:35 A.M. a tour was conducted of the F wing with Staff C3 and Y. Observation of the break room area revealed a power strip with two of six receptacles in use plugged into a power strip with three of four receptacles in use that was plugged into the wall receptacle.
In interviews during the tours, Staff C3 confirmed the observations.