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Based on observations, on April 17, 2014 at 9:00 AM to 4:45 PM, while on tour with facility staff, the facility failed to maintain fire retardant applications on exposed structural steel to maintain the approved construction classification of the building. Failure to maintain the fire retardant coating can lead to early structural failure of the steel member in a fire event, endangering the patients, staff, and other building occupants.


The findings include:


Building 13 on the first floor inside the emergency generator room, it was observed multiple structural members which had the fire retardant coating scraped off exposing the structural support member. Facility was plan-approved as a Type II (111) classification and fire retardant materials must be replaced to maintain the rating in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.1.6.1, 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 19.7.6.


These findings were confirmed with the Operations & Management Consultant Manager, Plant Operations Manager, and Maintenance Operations Manager during the closing conference April 17, 2014 at 5:00 PM.

Based on observations, on April 17, 2014 at 9:00 AM to 4:45 PM during tour with facility staff, the facility failed to maintain the proper operation of fire door assemblies to properly self-close and latch upon release to maintain the fire resistance rated barrier penetration. Failure to maintain the fire door assembly will allow for the travel of fire and smoke gases from one compartment to another, endangering patients, staff, or other building occupants.


The findings include:


1. Building 12 East Stairwell door to the corridor was found to be out of alignment and would not come to a fully closed and latched position upon release.

2. Building 12 1st Floor Room 40 cross corridor doors at the Dental Lab's right side door failed to come to a fully closed and latched position upon release.

3. Building 13 3rd Floor Center Stairwell by elevators' north door observed to be damaged and not properly sealing to the frame to maintain proper barrier separation and safety of the egress stairwell.

4. Building 13, 2nd Floor Laundry Chute room, fire door to chute was found in the 'open' position as the door closer device had failed to bring the door to a fully closed and latched position to maintain the fire resistance rated barrier.

Fire doors shall be maintained in operable condition at all times to include the proper self-closing and fully latching of the doors to maintain the fire-rated barrier penetration, in accordance with NFPA 80 (1999) 15-1, 15-1.2, 15-2.4, 15-2.5, NFPA 101 (2000) 4.5.7, 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.


These findings were confirmed with the Operations & Management Consultant Manager, Plant Operations Manager, and Maintenance Operations Manager during the closing conference April 17, 2014 at 5:00 PM.

Based on observations, on April 17, 2014 at 9:00 AM to 4:45 PM while on tour with facility staff, the facility failed to maintain required fire/smoke barriers to resist the passage of smoke and flames, which could endanger the patients, staff, and other building occupants.


The findings include:


1. Building 12, 2nd Floor Wing 2F, it was observed in the Pantry Room multiple ceiling tiles which have become damaged, with discoloration present.


2. Building 13 throughout facility on all floors, it was observed multiple ceiling tiles which have become damaged, with discoloration present.


3. Building 58 in the East Wing, it was observed multiple ceiling tiles which have become damaged, with discoloration present.


4. Building Wood Shop in the office, it was observed a pipe penetration through the fire-rated wall assembly, which had not been properly filled to prevent the passage of fire or smoke gases.


5. Building 36B, it was observed that a fire-rated ceiling tile in the horizontal position of the grid ceiling had been dislodged and was open just inside the entry door.


6. Building 7 in the Mechanical Room 23, it was observed inside the room multiple penetrations of pipes which had not been properly sealed to maintain the fire-rated ceiling and wall penetrations to include a large 4 X 2 opening, left unsealed in the ceiling.


Fire and Smoke barriers shall be maintained at all times to prevent the passage of fire or smoke gases from one compartment to another, to include at the end of a work day with proper fire and smoke stop systems in accordance with NFPA 101 (2000) 4.5.7, 4.6.12.1, 8.2.3.2.3.1, 8.2.3.2.4.1, 8.2.3.2.4.2(1-4), 8.2.3.2.4, 19.3.7.1, 19.7.6.


These findings were confirmed with the Operations & Management Consultant Manager, Plant Operations Manager, and Maintenance Operations Manager during the closing conference April 17, 2014 at 5:00 PM.

Based on review of facility records, the facility failed to provide evidence of fire drills being conducted at least once per shift per quarter, which can lead to failure of facility staff to perform properly during emergency events, which can lead to injury or loss of patients, staff, or other building occupants.

The findings include:


On April 16, 2014 at 9:00 AM to 4:00 PM during record reviews with facility staff, the facility was unable at time of survey to provide documentation that fire drills were conducted once per shift per quarter for all occupied housing facilities.


Fire Drill Logs for the 1st shift 1st quarter of 2014 Building 36D. The 1st shift, 2nd quarter of 2014 Buildings 13-2E, Wards 17, 32N, and 32S; The 1st shift, 3rd quarter of 2013 Buildings 12-2F, 13-1W, 13-1E, 13-2W, 13-2E, Ward 17; The 1st shift 4th quarter of 2013 buildings 58E, 57W, 57E, 12-2F, 12-3C, 13-2E, Ward 10, 32N, 36D.


Fire Drill Logs for the 2nd shift, 2nd quarter of 2013 Buildings 13-1W, 13-1E, 13-2W,13-2E; The 2nd shift 3rd quarter of 2013 buildings 13-1W, 13-1E, 13-2E, 36B; The 2nd shift 4th quarter of 2013 buildings 57W, 57E.


Fire Drill Logs for the 3rd shift, 1st quarter of 2014 Building 36D; The 3rd shift, 2nd quarter of 2013 Buildings 13-1W, 13-1E, 13-2W, 13-2E, Ward 8, Ward 9; The 3rd shift, 4th quarter of 2013, Buildings Ward 7, 36B.


Upon review of the facility's documents, it was noted during the record reviews that security officers were using multiple abbreviations for identifying the buildings on campus for which they conducted drills. Supervisor for the Security staff had to assist in getting documents properly labeled. Upon completion of this assistance, it was still found that multiple buildings which are utilized for housing patients had not documented receiving a fire drill once per shift per quarter, in accordance with NFPA 99 (1999) 12-4.1.2.10(d)(3), NFPA 101 (2000) 4.7.1, 4.7.2, 4.7.3, 4.7.4, 4.7.5, 4.7.6, 19.7.1.2.


These findings were confirmed with the Operations & Management Consultant Manager, Plant Operations Manager, and Maintenance Operations Manager during the closing conference April 17, 2014 at 5:00 PM.

Based on observations and staff interviews on April 17, 2014 from 9:00 AM to 4:45 PM while on tour with facility staff, it was determined that the facility failed to maintain, test, and inspect patient care equipment, which can render a piece of equipment out of compliance, and could fail to perform properly, endangering the patients, staff, and other building occupants.


The findings include:


Building 13 on the 3r d floor West Wing in the Physical Therapy Gym, it was observed multiple patient care appliances, which were labeled as having a last certification and testing completed on 2/19/2013 by the facility's bio-medical equipment company. Equipment is required to be tested annually, and was found to be out of compliance for a total of five appliances. The Floor Director and Maintenance Technician acknowledged the equipment was not in compliance at the time of survey and the bio-medical company will be contacted. All equipment shall be properly serviced and repaired in accordance with NFPA 70 (1999) Article 517, NFPA 99 (1999) 7-5.1.2, 7-5.1.3, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.3.2.3, 19.3.2.4, 19.5.1, 19.7.6.


Based on observations, on April 17, 2014 from 9:00 AM to 4:45 PM during tour with facility staff, the facility failed to maintain electrical equipment and wiring, in accordance with the National Electric Code (N.E.C.), NFPA 70, which could endanger the patients, staff, and other building occupants.


The findings include:


1. Building 12 on the 1st Floor in the Pharmacy Area Room, 45 Medication Stores, it was observed a multi-plug power tap device in use powering a fan and refrigerator in lieu of proper outlet power.

2. Building 12 on the 1st Floor in the Pharmacy Area, it was observed there were multiple outlets provided in the space, were older duplex NON-grounded receptacles which had equipment that were three-prong grounded appliances, utilizing them for power with the grounding prongs removed, in violation of the manufacturer's requirements.


3. Building 12 Lab Area, it was observed in use a multi-plug power tap device in use powering a toaster, radio, refrigerator, and coffee pot from an older duplex NON-grounded receptacle with the power tap cord not having a ground prong, utilizing them for power with the grounding prongs removed, in violation of the manufacturer's requirements.


4. Building Pump Plant, it was observed exterior of the building at the sump pump pit, the exterior conduit for the main electrical pump assembly has become damaged and was split open, exposing the electrical wiring inside to the weather.


5. Building 13 on the 3rd Floor East Wing, Room 58, it was observed in use a multi-plug power tap device powering a curling hair iron, in lieu of proper outlet power.


6. Building 13, 2nd Floor West Wing Medication Room, it was observed two refrigerators utilizing a multi-plug power tap device in lieu of proper outlet power.


7. Building 58, West Wing, it was observed in the Medication Room, a refrigerator utilizing a multi-plug power tap device in lieu of proper outlet power.


8. Building 58, Center Vending Room, it was observed an electrical J-box powering a vending drink machine which was not provided with a cover plate device, exposing the internal wires.


9. Building 58 East Wing, it was observed in the Medication Room a refrigerator utilizing a multi-plug power tap device in lieu of proper outlet power.


10. Building 57 East Wing, it was observed in the Medication Room a refrigerator utilizing a multi-plug power tap device in lieu of proper outlet power.


11. Wood Working and Activities Building in the Soda Storage Room office, it was observed in use an extension cord device in lieu of proper outlet power.


12. Building 36B, it was observed in the Medication Room, a refrigerator utilizing a multi-plug power tap device in lieu of proper outlet power.


13. Building 32 North Wing, it was observed in the Medication Room a refrigerator utilizing a multi-plug power tap device in lieu of proper outlet power.


Electrical appliances, wiring, and cords shall be properly utilized in accordance with NFPA 70 (1999) Article 110-3(b), 370-17(a-d), 370-25(a-c), 400-7(a-b), 400-8, 440-55(a-c), NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.5.7, 4.6.12.1, 9.2.1, 19.5.1, 19.7.6.


These findings were confirmed with the Operations & Management Consultant Manager, Plant Operations Manager, and Maintenance Operations Manager during the closing conference April 17, 2014 at 5:00 PM.