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Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. The facility census was 24..


1. Observation on 9/26/18, during the facility tour, showed the following;

-designated behavioral health exit requires patients, staff and visitors to walk 40 feet to a hard surface. Forty feet of path to hardpath consists of a grass surface.

During an interview on 9/26/18 at 12:10 P.M., the Vice President confirmed the observation.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:
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7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and interview, facility staff failed to separate designated exit corridors from hazardous areas. The facility census was 24.

1. Observation on 9/26/18, during the Life Safety Code (LSC) tour, showed the dividing corridor between the ICU corridor and the outpatient medical wing had a large dumpster stored in the corridor. Further observation showed the dumpster contained paper and plastic trash. Observation showed the dumpster on an exit corridor.

Observation on 9/26/18, during the LSC tour, showed the corridor of the operating room corridor had two large dumpster's stored in the corridor. Further observation showed the dumpster's contained soiled linen and paper and plastic trash. Observation showed the dumpster's stored on an exit corridor.

During an interview on 9/26/18 at 11:06 A.M., the Director of Plant Operations confirmed the observation.


19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft 2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection per NFPA 72, National Fire Alarm and Signaling Code. The facility census was 24..

Observations on 9/26/18, during the facility tour, showed the ICU waiting room open to the designated exit corridor. Observation showed the room did not have smoke detector coverage.

During an interview on 9/26/18 at 11:03 A..M., the Vice President confirmed the observation.

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 interview, the facility staff failed to ensure the sprinkler supervisory alarms were installed and monitored per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was 24.

Observations on 9/26/18, during the facility tour, showed a sprinkler system water supply pipe connected to the facility sprinkler system water supply in the facility yard. Observation did not show an electronic supervising device connected to the valve controlling facility sprinkler system water supply.

During an interview on 9/26/18 at 2:34 P.M., the Director of Plant Operations confirmed the observation.

NFPA 101, 2012 edition, Section 9.7.2 states:

"9.7.2 Supervision.

9.7.2.1* Supervisory Signals. Where supervised automatic
sprinkler systems are required by another section of this Code,
supervisory attachments shall be installed and monitored for
integrity in accordance with NFPA 72, National Fire Alarm and
Signaling Code, and a distinctive supervisory signal shall be provided
to indicate a condition that would impair the satisfactory
operation of the sprinkler system. Supervisory signals shall
sound and shall be displayed either at a location within the
protected building that is constantly attended by qualified personnel
or at an approved, remotely located receiving facility."

NFPA 72, 2010 edition, section 17.16 states:

"17.16 Supervisory Signal-Initiating Devices.

17.16.1 Control Valve Supervisory Signal-Initiating Device.

17.16.1.1 Two separate and distinct signals shall be initiated:
one indicating movement of the valve from its normal position
(off-normal), and the other indicating restoration of the valve
to its normal position.

17.16.1.2 The off-normal signal shall be initiated during the
first two revolutions of the handwheel or during one-fifth of
the travel distance of the valve control apparatus from its normal
position.

17.16.1.3 The off-normal signal shall not be restored at any
valve position except normal.

17.16.1.4 An initiating device for supervising the position of a
control valve shall not interfere with the operation of the
valve, obstruct the view of its indicator, or prevent access for
valve maintenance."

Please refer to NFPA 72, 2010 ed. Table 14.4.5 (15L), Table 14.4.2.2 (14I) for testing requirements.

Based on record review and interview, the facility failed to ensure that all building systems had been assigned a risk assessment category. The facility census was 24.

1. Review of the facility documents for fire safety, building system tests, and policies showed no assessment of which systems were critical for patient safety.

During an interview on 9/26/18 at 2:35 P.M. the Vice President said the facility did not have a risk categorical assessment.

NFPA 99 2012 - chapter four Fundamentals, 4.1-4.3