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Based on observation and facility staff interview, the facility staff failed to ensure the range hood was maintained in accordance with National Fire Protection Association standards. The range hood did not have a grease removal drip tray. Failure to provide a grease removal drip tray has the potential to affect all building occupants in the event of a fire. The facility census was 221.

Observation during the Life Safety Code (LSC) tour on 5/17/2018 did not show a grease removal drip tray attached to the range hood.

National Fire Protection Association (NFPA) 96, 2011 edition states:


6.2.4 Grease Drip Trays.

6.2.4.1 Grease filters shall be equipped with a grease drip tray
beneath their lower edges.

6.2.4.2 Grease drip trays shall be kept to the minimum size
needed to collect grease.

6.2.4.3 Grease drip trays shall be pitched to drain into an enclosed
metal container having a capacity not exceeding 3.8 L
(1 gal).

During an interview on 5/17/2018 at 2:07 P.M., the Director of Facilities Management stated he believed the range hood inspection company conducted the inspection per code requirements.

Based on observation and facility staff interview, the facility 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. The facility census was 221.

1. Observation on 5/17/18, during the facility tour, showed the Professional Development Classroom Suite designated exit corridor did not have smoke detector coverage. Observation showed the corridor measured approximately 90 feet in length.

During an interview on 5/17/18 at 6:27 P.M., the Director of Facilities Management stated he believed the fire alarm installation/inspection company installed the fire alarm per code requirements.

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 two of two enclosed court yards. This deficient practice potentially could affect all residents, staff, and occupants in the event of a fire. The facility census was 221.

Observation on 5/16/18 at 4:00 P.M., of the facility's enclosed court yards did not show audible and visual fire alarm devices.

During an interview on 5/17/18 at 6:27 P.M., the Director of Facilities Management stated he believed the fire alarm installation/inspection company installed the fire alarm per code requirements.

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, the facility staff failed to provide sprinkler coverage in accordance with NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. Facility staff failed to provide correct application of sprinkler heads for the entire building. This deficient practice could delay activation of the sprinkler system for prompt fire extinguishment. This deficient practice has the potential to affect all facility residents. The facility census was 221.

Observation on 5/16/2018, during the facility tour, on Cardiology #2 hallway, showed a mix of 10 quick response sprinkler heads and 12 standard response sprinkler heads in the same compartmented space.

During an interview on 5/17/18 at 6:30 P.M., the Director of Facilities Management stated he believed the sprinkler installation/inspection company installed the fire alarm per code requirements.


NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition states:

8.3.3 Thermal Sensitivity.
8.3.3.1* Sprinklers in light hazard occupancies shall be one of
the following:
(1) Quick-response type as defined in 3.6.4.7
(2) Residential sprinklers in accordance with the requirements
of 8.4.5
(3) Standard-response sprinklers used for modifications or
additions to existing light hazard systems equipped with
standard-response sprinklers
(4) Standard-response sprinklers used where individual
standard-response sprinklers are replaced in existing light
hazard systems
8.3.3.2 Where quick-response sprinklers are installed, all
sprinklers within a compartment shall be quick-response unless
otherwise permitted in 8.3.3.3.
8.3.3.3 Where there are no listed quick-response sprinklers
in the temperature range required, standard-response sprinklers
shall be permitted to be used.
8.3.3.4 When existing light hazard systems are converted to
use quick-response or residential sprinklers, all sprinklers in a
compartmented space shall be changed.

Based on observation and facility staff interview, facility staff failed to ensure corridor doors latched. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure corridor doors latch 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. The facility census was 221.

Observation on 5/15-17/2018, during the building tour, showed nine patient corridor doors equipped with manual key operated deadbolts requiring manual manipulation to latch in the Stephens Adult Psych I unit.

During an interview on 5/17/2018, the Director of Facilities Management stated said he did not know when the dead bolt locks were installed on the patient doors.