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Based on document review, the facility failed to establish that all corridor wall coverings met the flame spread specification requirements.

Findings include:

The facility did not have flame spread documentation for all areas of the building, missing was documentation for the corridor spaces.

Based on document review, the facility failed to establish that all rooms/suites wall coverings met the flame spread specification requirements.

Findings include:

The facility did not have flame spread documentation for all areas of the building, missing was documentation for the business office spaces and the clinical office.

Based on observation, the facility failed to ensure that all corridor doors were properly constructed and were free from impediments from closure.

Findings include:

The below listed corridor doors had the following problems:

1) The laundry room (within the east smoke compartment) had an unrated corridor door and the door had an approximately 10" by 10" wire glass vision panel, which was modified with non-manufacturer's screws to hold the vision panel in place. Note: This laundry room was 9.5' by 8', so the room is not considered a hazardous area and does not require a 1.5-hour fire-rated constructed door.

2) The northwest therapist office's corridor door was held open with a chair.

3) The northwest therapist office's corridor door was not fire-rated (same door identified in item #2 above). The door also had an unrated vision panel, and the vision panel was also not wire-mesh constructed.

Based on observation and document review, the facility failed to ensure that rated fire barriers were equipped with the properly fire-rated and constructed protective openings at the doorways.

Findings include:

1) The facility had a two-hour fire-rated barrier (per the facility's plans) separating the north fire compartment from the rest of the building. There were two protective openings in this wall, one was the communicating cross-corridor set of double doors and the other was a single communicating door found between the conference room and the dining room. The conference room door was unrated, and was constructed to meet a 20-minute nominal fire-rated door (however, requires an 1.5-hour fire-rated door)

2) The smoke barrier cross-corridor set of doors between the southwest and west smoke compartments were solid constructed doors without the required vision panels in each leaf.

Based on interview and document review, the facility failed to ensure that staff understood their written fire safety policy and how to respond to the fire alarm system.

Findings include:

Before the fire drill, interviews with random staff members on how they would respond if they encountered a fire revealed the following:

- The Housekeeper responded that he would go talk with his supervisor. Note: It was also revealed that he had been working at the facility for just over a month.

- Two Psychiatric Techs responded that they would broadcast the fire over their hand held walkie-talkies radios. The walkie-talkies radios were only issued to certain staff members and was not discussed in the facility's written fire safety policy. These two staff members could not provide additional information found in their written fire safety plan about how to respond in the event of a fire without further prompting. These staff members had been at the facility for approximately two years.

Note: During the fire drill staff responded by performing specific, limited tasks/components of the fire drill (guard doors or move carts from the corridors) after hearing the fire alarm. However from the interviews, staff was unfamiliar with all components of the written fire safety plan and may not know how to respond readily if they discover a fire.

Based on observation, the facility failed to ensure that highly flammable decorations were not used within the building.

Findings include:

The following facility doors were covered in holiday wrapping (flammable) paper:

1) The business suite hall door (near medical records) was wrapped in holiday paper.
2) The medical records door was wrapped in holiday paper.
3) The middle smoke compartment's west classroom's corridor door was wrapped in holiday paper.
4) The middle smoke compartment's east classroom's corridor door was wrapped in holiday paper.
5) The east smoke compartment therapist office corridor door was wrapped in holiday paper.
6) The east smoke compartment's classroom corridor door was wrapped in holiday paper.
7) The west smoke compartment's north dayroom's therapist office's door was wrapped with holiday paper.

Based on observation, the facility failed to ensure that all smoke barrier penetrations were protected.

Findings include:

In data room, near the dietary department, there were 19 unprotected conduits openings at the floor.

NFPA 101
Chapter 18-5.1.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction.

NFPA 70

COVERS:
NFPA 70, Section 370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixed canopy.

NFPA 70, Section 410-56(d) Faceplates. Metal faceplates shall be ferrous metal not less than 0.030 inch in thickness or nonferrous metal not less than 0.040 inch in thickness. Metal faceplates shall be grounded. Faceplates of insulating material shall be noncombustible, and not less than 0.10 inch in thickness but shall be permitted to be less than 0.10 inch in thickness if formed or reinforced to provide adequate mechanical strength.

EXTENSION CORDS:
NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure
NFPA 70, Section 305-4(h) Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protections shall be provided to avoid damage.

ITEMS NEAR ELECTRICAL EQUIPMENT
NFPA 70, Section 110-26 (a) (1) Depth of Working Space. The depth of working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts is such are exposed or from the enclosure front or opening is such are enclosed.
Nominal Voltage to Ground of 0 -150 = 3 feet
Nominal Voltage to Ground of 150 - 600 = 4 feet

BRANCH CIRCUIT, FEEDER, AND SERVICE CALCULATIONS
NFPA 70, Section 220-3 Computation of Branch Circuit Loads. Branch circuit loads shall be computed as shown in (a) through (c).
(a) Lighting Loads for Specified Occupancies.
(b) Other Loads - All Occupancies.
(c) Loads for Additions to Existing Installations.


Based on observation, the facility failed to ensure that the electrical installations within the building conformed to NFPA 70, National Electrical Code.

Findings include:

The below listed locations had the following electrical problems:

1) In the receptionist office, the facility was using electrical power strips as permanent wiring. The room had three electrical power strips being utilized as extension cords/permanent wiring. One power strip was near the refrigerator with five appliances on it. A second power strip was under the desk with five appliances connected to it. And a third power strip was plugged into the west wall outlet with two appliances connected to it; a clock and a postage machine.

Note: The facility must be mindful to ensure that the capacity for the circuits do not get overloaded. Mapping of the circuits within the building is strongly recommended for monitoring and re-assigning electrical appliances as needed.

2) In the west smoke compartment's south day room, one of the rooms electrical face plates was missing from the duplex outlet.

Based on document review, the facility failed to establish that all corridor wall coverings met the flame spread specification requirements.

Findings include:

The facility did not have flame spread documentation for all areas of the building, missing was documentation for the corridor spaces.

Based on document review, the facility failed to establish that all rooms/suites wall coverings met the flame spread specification requirements.

Findings include:

The facility did not have flame spread documentation for all areas of the building, missing was documentation for the business office spaces and the clinical office.

Based on observation, the facility failed to ensure that all corridor doors were properly constructed and were free from impediments from closure.

Findings include:

The below listed corridor doors had the following problems:

1) The laundry room (within the east smoke compartment) had an unrated corridor door and the door had an approximately 10" by 10" wire glass vision panel, which was modified with non-manufacturer's screws to hold the vision panel in place. Note: This laundry room was 9.5' by 8', so the room is not considered a hazardous area and does not require a 1.5-hour fire-rated constructed door.

2) The northwest therapist office's corridor door was held open with a chair.

3) The northwest therapist office's corridor door was not fire-rated (same door identified in item #2 above). The door also had an unrated vision panel, and the vision panel was also not wire-mesh constructed.

Based on observation and document review, the facility failed to ensure that rated fire barriers were equipped with the properly fire-rated and constructed protective openings at the doorways.

Findings include:

1) The facility had a two-hour fire-rated barrier (per the facility's plans) separating the north fire compartment from the rest of the building. There were two protective openings in this wall, one was the communicating cross-corridor set of double doors and the other was a single communicating door found between the conference room and the dining room. The conference room door was unrated, and was constructed to meet a 20-minute nominal fire-rated door (however, requires an 1.5-hour fire-rated door)

2) The smoke barrier cross-corridor set of doors between the southwest and west smoke compartments were solid constructed doors without the required vision panels in each leaf.

Based on interview and document review, the facility failed to ensure that staff understood their written fire safety policy and how to respond to the fire alarm system.

Findings include:

Before the fire drill, interviews with random staff members on how they would respond if they encountered a fire revealed the following:

- The Housekeeper responded that he would go talk with his supervisor. Note: It was also revealed that he had been working at the facility for just over a month.

- Two Psychiatric Techs responded that they would broadcast the fire over their hand held walkie-talkies radios. The walkie-talkies radios were only issued to certain staff members and was not discussed in the facility's written fire safety policy. These two staff members could not provide additional information found in their written fire safety plan about how to respond in the event of a fire without further prompting. These staff members had been at the facility for approximately two years.

Note: During the fire drill staff responded by performing specific, limited tasks/components of the fire drill (guard doors or move carts from the corridors) after hearing the fire alarm. However from the interviews, staff was unfamiliar with all components of the written fire safety plan and may not know how to respond readily if they discover a fire.

Based on observation, the facility failed to ensure that highly flammable decorations were not used within the building.

Findings include:

The following facility doors were covered in holiday wrapping (flammable) paper:

1) The business suite hall door (near medical records) was wrapped in holiday paper.
2) The medical records door was wrapped in holiday paper.
3) The middle smoke compartment's west classroom's corridor door was wrapped in holiday paper.
4) The middle smoke compartment's east classroom's corridor door was wrapped in holiday paper.
5) The east smoke compartment therapist office corridor door was wrapped in holiday paper.
6) The east smoke compartment's classroom corridor door was wrapped in holiday paper.
7) The west smoke compartment's north dayroom's therapist office's door was wrapped with holiday paper.

Based on observation, the facility failed to ensure that all smoke barrier penetrations were protected.

Findings include:

In data room, near the dietary department, there were 19 unprotected conduits openings at the floor.

NFPA 101
Chapter 18-5.1.1 Utilities shall comply with the provisions of Section 9-1
Chapter 9-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction.

NFPA 70

COVERS:
NFPA 70, Section 370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixed canopy.

NFPA 70, Section 410-56(d) Faceplates. Metal faceplates shall be ferrous metal not less than 0.030 inch in thickness or nonferrous metal not less than 0.040 inch in thickness. Metal faceplates shall be grounded. Faceplates of insulating material shall be noncombustible, and not less than 0.10 inch in thickness but shall be permitted to be less than 0.10 inch in thickness if formed or reinforced to provide adequate mechanical strength.

EXTENSION CORDS:
NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure
NFPA 70, Section 305-4(h) Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protections shall be provided to avoid damage.

ITEMS NEAR ELECTRICAL EQUIPMENT
NFPA 70, Section 110-26 (a) (1) Depth of Working Space. The depth of working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts is such are exposed or from the enclosure front or opening is such are enclosed.
Nominal Voltage to Ground of 0 -150 = 3 feet
Nominal Voltage to Ground of 150 - 600 = 4 feet

BRANCH CIRCUIT, FEEDER, AND SERVICE CALCULATIONS
NFPA 70, Section 220-3 Computation of Branch Circuit Loads. Branch circuit loads shall be computed as shown in (a) through (c).
(a) Lighting Loads for Specified Occupancies.
(b) Other Loads - All Occupancies.
(c) Loads for Additions to Existing Installations.


Based on observation, the facility failed to ensure that the electrical installations within the building conformed to NFPA 70, National Electrical Code.

Findings include:

The below listed locations had the following electrical problems:

1) In the receptionist office, the facility was using electrical power strips as permanent wiring. The room had three electrical power strips being utilized as extension cords/permanent wiring. One power strip was near the refrigerator with five appliances on it. A second power strip was under the desk with five appliances connected to it. And a third power strip was plugged into the west wall outlet with two appliances connected to it; a clock and a postage machine.

Note: The facility must be mindful to ensure that the capacity for the circuits do not get overloaded. Mapping of the circuits within the building is strongly recommended for monitoring and re-assigning electrical appliances as needed.

2) In the west smoke compartment's south day room, one of the rooms electrical face plates was missing from the duplex outlet.