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Based on observation and staff interview, the facility did not properly enclose stairways used for exits. NFPA 101 (2012) 7.1.3.2.1. This deficient practice could affect all 271 patients.

Findings include:

On a facility tour between the hours of 10:30 AM and 04:00 PM on February 04, 2019, it was revealed that combustible floor cleaning pads were found under the egress stairwell in the Atrium section of the Main Building.


This deficient practice was verified by the Manager of Engineering Services at the time of discovery.

Based on observation and staff interview, the facility did not properly separate and protect hazardous areas. 19.3.2.1. This deficient practice could affect all patients within the smoke compartment.

Findings include:

On a facility tour between the hours of 10:30 AM and 04:00 PM on February 04, 2019, observation revealed that Room A32, in the Main Building, which is a storage room of over 100 square feet, had a cart blocking the self-closing door from being able to close and latch.


This deficient practice was verified by the Manager of Engineering Services at the time of discovery.

Based on observation and staff interview, the facility did not maintain the fire alarm system in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code with records of maintenance and testing being readily available. 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could effect all 271 patients.

Findings include:

On a facility tour between the hours of 10:30 AM and 04:00 PM on February 04, 2019, it was revealed that the Main Building, 2nd floor, Fan Room #10, fire annunciator panel indicated a trouble alarm.


This deficient practice was verified by the Facility Engineer at the time of discovery.

Based on document review and staff interview, the facility did not properly implement a fire watch protocol for when the fire alarm system is out of service for more than 4 hours in 24-hour period within accordance of NFPA 101 (2012) Life Safety Code, section 9.6.1.6. This deficient practice could affect all 271 patients.

Findings include:

On a facility tour between the hours of 10:30 AM and 04:00 PM on February 04, 2019, it was revealed that the Alternate Life Safety Plan stated that Fire Watch would be initiated when the fire alarm system is out of order for a period of 10 hours or more in a 24-hour period, instead of four hours in a 24-hour period.


This deficient practice was verified by the Supervisor of Maintenance and Engineering Services at the time of discovery.

Based on documentation review and staff interview, the facility did not conduct fire drills at unexpected times and varied conditions. The facility also did not verify the transmission of a fire alarm signal when fire drills were conducted. This is not in accordance with 2012 edition of NFPA 101 (2012), Life Safety Code, Section 19.7.1.4. This deficient practice could affect all 271 patients.

Findings include:

On a facility tour between the hours of 10:30 AM and 04:00 PM on February 04, 2019, it was revealed that the facility could not provide evidence of having conducted a fire drill for eh second shift during the third quarter of 2018.


This deficient practice was verified by the Chief Engineer at the time of the discovery.

Based on observation and staff interview, the facility failed to ensure combustible decorations met flame spread and heat release requirements within accordance with NFPA 101 (2012), Life Safety Code, section 19.7.5.6. This deficient practice could effect all patients within the smoke compartment.

Findings include:

On a facility tour between the hours of 9:00 AM and 11:30 AM on February 05, 2019, it was revealed that the OPC Building, second floor, IT room had a large paper tent that covered approximately four office cubicles.


This deficient practice was verified by the Facility Engineer at the time of discovery.