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Based on observations and interview, the facility failed to maintain the minimum construction requirements for health care occupancies. In case of fire, failure to maintain the approved minimum construction requirements could allow smoke and fire to quickly spread from a room of origin, endangering patients, staff, and other building occupants.


The findings include:


1. On 05/06/2015 at 9:47 AM during facility tour of Building 36D with staff, it was observed the drop ceiling in corridors did not have the required safety clips that provided the fire rating for the ceiling. Inspection of the ceiling reflected some safety clips were missing and others were not in place.

2. On 05/06/2015 at 10:22 AM during facility tour of Building 36D with staff, it was observed the drop ceiling in corridors did not have the required safety clips that provided the fire rating for the ceiling. Inspection of the ceiling reflected some safety clips were missing and others were not in place.

Minimum construction type required for facilities housing residents without an automatic fire sprinkler system shall be maintained in accordance with NFPA 101 (2000) 4.5.6, 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, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.

Based on observations and interview, the facility failed to maintain the proper operation of fire/smoke 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:


Bldg # 7

1. At Building # 7 on May 6, 2015 at 9:00 am, it was observed at the West corridor main shower and bathroom, fire rated 45 minute door was damaged and not in alignment with the door frame. The automatic door closer device has been removed. A door stop device was installed to keep the door in the open position. The door did not close and maintain a smoke tight fit into the door frame. This condition exposes the area to the spread of fire and the passage of smoke.

2. Observations of the Staff Bathroom # 21 at 9:30 am, revealed the door was damaged; the door did not close and maintain a smoke tight into the door frame. This condition exposes the area to the spread of fire and the passage of smoke.

3. Observations of the Soiled Linen and Laundry Room # 22 at 9:45 am, revealed the 45 minute fire-rated door was damaged, The door did not close and maintain a smoke tight into the door frame. This condition exposes the area to the spread of fire and the passage of smoke.

4. Observations of Room # 23 at 9:55 am, revealed the 45 minute fire-rated door was damaged. The door did not close and maintain a smoke tight into the door frame. The automatic door closer device is damaged and not secured to the door. The lever arm has been disconnected. This condition exposes the area to the spread of fire and the passage of smoke.

Bldg #8

1. At Building # 8 on May 5, 2015 at 10:30 am, it was observed at the West Corridor Room # 19, the storage room door was damaged and not in alignment with the door frame. The door did not close and maintain a smoke tight fit. This condition exposes the area to the spread of fire and the passage of smoke into adjoining compartments.

Bldg # 9

1. At Building # 9 on May 5, 2015 at 9:00 am, it was observed at the Laundry Room #23, the 45 minute fire-rated door is damaged. The door leaf is split and broken. The door knob and latch device is damaged and does not function properly to maintain a smoke tight fit into the frame. This condition exposes the area to the spread of fire and the passage of smoke.

Bldg #12

1. On May 6, 2015 at 1:41 PM while on tour with facility staff in Building 12, 3rd Floor West Laundry Chute Room, it was observed that the fire-rated automatic door closer device was missing and the door assembly was not properly sealed into the wall to maintain the integrity of the fire-rated assembly.

2. On May 6, 2015 at 2:59 PM while on tour with facility staff in Building 12, 1st Floor Cross Corridor door to Building 13 by Room 125, it was observed that the labeled 90 minute fire resistance-rated door in a two hour fire resistance rated wall, failed to properly latch in the closed position upon release.

Bldg # 13

1. On May 6, 2015 at 3:06 PM while on tour with facility staff in Building 13, 1st floor Cross Corridor double doors, it was observed that the labeled 90 minute fire resistance-rated door in a two hour fire resistance-rated wall failed to properly latch in the closed position upon release.

Bldg # 15

1. At Building # 15 on May 7, 2015 at 10:00 am, it was observed at the East Corridor, the cross corridor doors are damaged. The left side door leaf is damaged, out of alignment and does not close properly. The left side door leaf drags on the ground and does not maintain a smoke tight fit. This condition exposes the area to the spread of fire and the passage of smoke into adjoining compartments.


Fire and smoke 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, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.

Based on staff interviews, the facility failed to familiarize personnel with the use of building safety features as outlined in the Fire Safety Plan. In case of fire, this deficient practice could negatively affect the staff's capability to respond in a prompt, effective manner, endangering the patients, staff, and other building occupants.


The findings include:


1. On 05/06/2015 at 9:25 AM during facility tour of Building 36D with staff, a Caregiver was interviewed. The interview reflected the person did not have knowledge on how to activate the manual fire alarm system and was not aware she had the activation key for the manual pull station on her key ring. The interview further reflected that security personnel activated the fire alarm system while conducting fire drills and did not familiarize Building 36D staff on activating the fire alarm system.

2. On 05/06/2015 at 10:04 AM during facility tour of Building 36D with staff, a custodial person was interviewed. The interview reflected the person did not have keys to activate the manual fire alarm system, and did not participate in quarterly fire drills.

3. On May 6, 2015 at 10:30 AM while on tour with facility staff in Building 13, during direct questioning to custodial staff, the person did not have keys to activate the facilities' fire alarm system, access to secured fire extinguisher cabinets, and did not participate in quarterly fire drills.

In interview with Operations & Management Consultant on May 6, 2015 at 4:25 PM, it was advised that the housekeeping custodial staff are contract employees from an outside vendor. It was acknowledged after discussion that the housekeeping custodial staff must have access to the key for use of the fire alarm pullstation's and fire extinguishers, and they shall participate as staff in quarterly fire drills.

Automatic and manual initiating devices shall contribute to life safety, fire protection, and property conservation by providing a reliable means to signal other equipment
arranged to monitor the initiating devices and to initiate a response to those signals. All staff shall be capable of initiating the fire alarm system to initiate a response, in accordance with NFPA 72 (1999) 2-1.1, 2-1.2, 2-8.2.1, NFPA 101 (2000) 4.5.6, 4.5.7, 4.6.12.1, 4.6.12.3, 4.6.12.4, 4.7, 19.7, 19.7.2.3, 19.7.6.

These findings were confirmed with the Operations & Management Consultant Manager, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.

Based on staff interview and records review, the facility failed to maintain their fire alarm system in accordance with NFPA 72, maintaining the integrity of the system to alarm in the event of a fire to allow for the emergency egress and relocation of patients, staff, or other building occupants, which could result in injury or loss.


The findings include:


On May 4, 2015 from 10:00 AM to 4:30 PM during record review with facility staff, documentation provided for the inspection, testing, and maintenance of the fire alarm system indicated multiple batteries for the secondary power supply were out-of-date and in need of replacement. In discussion with the Operations & Management Consultant, it was acknowledged that a quote was signed on 3/13/2015, but no documentation could be provided at time of survey to show that all 20 batteries were replaced.


Fire Alarm System deficiencies shall be corrected and properly documented in accordance with NFPA 72 (1999) 7-1, 7-1.1.2, 7-1.2, 7-3.2.1, NFPA 101 (2000) 4.6.12.1, 9.6.1.4, 9.6.1.7, 19.3.4.1, 19.7.6.


These findings were confirmed with the Operations & Management Consultant Manager, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.

Based on record review and interview, the facility failed to maintain their smoke detectors that are part of the fire alarm system, in accordance with NFPA 72, which can result in failure of the system to notify in the event of a fire, endangering patients, staff, and other building occupants.

The findings include:


On May 4, 2015 from 10:00 AM to 4:30 PM during record review with facility staff, documentation for sensitivity of all devices throughout the facility was last documented on 2/18/2013. No further documentation could be provided at time of survey to show detectors are within required manufacturer's range. Sensitivity testing shall be conducted every other year, in accordance with NFPA 72 (1999) 7-3.2.1, NFPA 101 (2000) 9.6.1.4, 9.6.1.7, 19.3.4.1.

These findings were confirmed with the Operations & Management Consultant Manager, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.

Based on observations and interview, the facility failed to inspect portable fire extinguishers as required by code. NFPA 10, which requires fire extinguishers be inspected manually at a minimum 30 day interval. In case of fire, this deficient practice could render the fire extinguishers unreliable for use, endangering the patients, staff, and other building occupants.

The findings include:


1. On 05/06/2015 at 9:42 AM during facility tour of Building 36D with staff, it was observed portable fire extinguishers in the facility did not have the required monthly inspection tag signed on a recurring basis. The monthly inspection signature record reflected 5 of the previous 12 months had not been signed.

2. On 05/06/2015 at 10:13 AM during facility tour of Building 36B with staff, it was observed portable fire extinguishers in the facility did not have the required monthly inspection tag signed on a recurring basis. The monthly inspection signature record reflected the last signature was dated November 2014.

Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record, in accordance with NFPA 10 (1998) 4-3.4, 4-3.4.1, 4-3.4.2, 4-3.4.3, NFPA 101 (2012) 4.5.7, 4.5.8, 4.6.12.1, 4.6.12.3, 4.6.12.4, 9.7.4.1, 19.3.5.12, 19.7.6.

These findings were confirmed with the Operations & Management Consultant Manager, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.

Based on observations and interview, the facility failed to maintain Ventilation Air Controls to ensure proper operation, which could lead to failure of the system to convey and exhaust odors and gases, and failure to prevent the spread of fire/smoke gases, which could potentially harm patients, staff, or other building occupants.

The findings include:

1. At Building # 9 on May 5, 2015 at 11:00 am, it was observed at West Corridor Room # 20, the Janitor's closet exhaust units are inoperable and non-functioning.

2. At Building # 9 on May 5, 2015 at 11:30 am, it was observed at East Corridor Room # 38, the Janitor's closet inoperable and non-functioning.

3. At Building # 9 on May 5, 2015 at 11:35 am, it was observed at Corridor Rest Room # 4, the exhaust units are inoperable and non-functioning.

Restrooms were not able to provide proper exhaust of waste vapors and gases, in accordance with NFPA 91 (1999) 7-1, 7-2, 7-3, 7-4, 7-5, 7-6, 7-7, NFPA 101 (2000) 4.6.12.1, 4.6.12.3, 4.6.12.4, 9.2.2, 19.5.2.1, 19.7.6.

These findings were confirmed with the Operations & Management Consultant Manager, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.

Based on record review and interview, the facility failed to maintain the Fire Suppression System for the commercial cooking equipment with regard to the inspection, testing, and maintenance, not less than every six months, which could result in the malfunction or failure of the system to properly perform during a fire, endangering the patients, staff, and other building occupants.

The findings include:


On May 4, 2015 from 10:00 AM to 4:30 PM during record review with staff, the facility provided documentation of inspection, testing, and maintenance of the fire suppression system for the coverage of the kitchen commercial cooking equipment. The documentation provided indicated that the contractor for the inspection, testing, and maintenance of the system did not perform the required service every six months. The services were conducted on 4/15/2014 and not again until 12/10/2014, for a total of eight months between service. Fire Suppression System shall be inspected, tested, and maintained every six months in accordance with NFPA 17A (1998) 5-3.1, 5-3.1.1, NFPA 96 (1998) 7-1, 7-1.1, 7-1.2, 7-2.2.1(d), 8-1.6, 9-1.2.2, NFPA 101 (2000) 9.2.3, 19.3.2.6.

These findings were confirmed with the Operations & Management Consultant Manager, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.

Based on observations and interview, the facility failed to maintain proper storage practices of gas cylinders. Failure to maintain proper storage practices can result in endangerment to patients, staff, and other building occupants.

The findings include:


1. On May 6, 2015 at 1:48 PM while on tour with facility staff in Building 12, 3rd Floor West Med Cart and Oxygen Storage Room, it was observed that a single e-sized oxygen cylinder was free-standing, unsecured from tipping or falling.

2. On May 6, 2015 at 1:52 PM while on tour with facility staff in Building 12, 3rd Floor Main Oxygen Storage Room across from Room 35, it was observed, (12) twelve Full e-sized oxygen cylinders, which were behind a loose chain free-standing, with no protection from falling or tipping. An open storage box was located right next to the bottles, but was covered by books and other debris.

3. On May 7, 2015 at 10:52 AM while on tour with facility staff in Building 13, 1st Floor East Crash Cart Room, it was observed a single e-sized oxygen cylinder free-standing, with no protection from falling or tipping.

Failure to properly secure compressed gases from tipping or falling can result in a dangerous and explosive discharge of the cylinder. Cylinders shall be properly protected, in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2, NFPA 101 (2000) 4.6.12.1, 19.3.2.4, 19.7.6.

These findings were confirmed with the Operations & Management Consultant Manager, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.

Based on observations and interview, 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. On May 5, 2015 at 1:20 PM while on tour with facility staff in the Boiler Building, it was observed a man-made light indicator, which had exposed wires protruding from a plug head assembly, not properly protected and appeared to be frayed and damaged.

2. On May 6, 2015 at 1:16 PM while on tour with facility staff at the East Front Entry- way to Building 12, it was observed an electrical cord plug head end protruding from the light fixture, in lieu of a properly provided weather proof outlet.

3. On May 6, 2015 at 1:34 PM while on tour with facility staff in Building 12, 3rd Floor West in the HVAC Room, it was observed an open ceiling electrical junction box with wiring protruding and capped with wire nuts, not properly secured with a junction box cover.

4. On May 6, 2015 at 2:11 PM while on tour with facility staff in Building 12, 2nd Floor East Room 88, it was observed a floor fan which had a missing ground pin for the plug head.

5. On May 6, 2015 at 2:18 PM while on tour with facility staff in Building 12, 2nd Floor East Room 30, it was observed a receptacle outlet which was missing the coverplate, exposing the internal wiring.

6. On May 6, 2015 at 2:25 PM while on tour with facility staff in Building 12 Central, Room 15, it was observed a refrigerator utilizing a relocatable powertap device in lieu of direct outlet power.

7. On May 6, 2015 at 2:28 PM while on tour with facility staff in Building 12 Central, Room 12, it was observed patient care equipment utilizing a relocatable powertap device in lieu of proper outlet power.

8. On May 6, 2015 at 2:31 PM while on tour with facility staff in Building 12 Central, Room 9, it was observed patient care equipment utilizing a relocatable powertap device in lieu of proper outlet power.

9. On May 6, 2015 at 2:32 PM while on tour with facility staff in Building 12 Central, Room 4, it was observed patient care equipment utilizing a relocatable powertap device in lieu of proper outlet power.

10. On May 6, 2015 at 2:46 PM while on tour with facility staff in Building 12 West, in corridor by Room 54, it was observed an electrical receptacle which has become damaged and loose in the wall junction box, allowing for the receptacle to move loosely in the box.


Electrical appliances, wiring, and cords shall be properly utilized, in accordance with NFPA 70 (1999) Article 110-3(b), 110.12(c), 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, Mechanical Supervisor, and Superintendent during the exit conference May 7, 2015 at 1:00 PM.