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Based on document review and staff interview, the facility failed to provide a building with a required construction type. This deficient practice may, during a fire emergency, affect patients, staff and visitors from gaining safe access to a discharge.

The finding is:

A. On 02/01/2022 at 10:45am accompanied by the D.F.O., the surveyor finds that the Center Building is constructed with reinforced concrete structural systems. The building's construction type appears to be type II (111) from historical documentation. This condition does not comply with 19.1.6.2 for a minimum type II (222) construction type. The facility's F.S.E.S. was observed to cover this deficiency, however, the F.S.E.S. dated 2014 is not updated/current.

B. On 02/01/2022 at 2:00pm accompanied by the D.F.O., the surveyor finds Third floor Center Building's Mechanical Room is concrete joist and beam construction with a monolithic plaster ceiling at the bottom. This plaster ceiling has large voids in it. The provider's F.S.E.S. is not updated/current to demonstrate how the floor assembly is at least two hour rated without the plaster ceiling.

Based on observation egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

A. On 02/01/2022 at 10:50am while accompanied by the D.F.O., on the Second floor Behavioral Unit between the abandoned compartment 2NW and compartment A a designated smoke compartment separation contains a door with a delayed egress which does not comply with 7.2.1.6.1 due to the following:
1. Staff did not have a means to manually reset the door to comply with 7.2.1.6.1.1(3)(d)
2. It could not be determined due to the location (Behavioral Unit) if the door complies with the requirements of 7.2.1.6.1.1(2) to deactivate upon loss of power.
3. There did not appear to be emergency lighting to comply with 7.2.1.6.1.1(5).
4. Upon activation of the door, no Behavioral Staff member appeared to investigate, required for security measures, to comply with 19.2.2.2.5.1.

B. On 02/01/2022 at 10:50am while accompanied by the D.F.O., on the Second floor Behavioral Unit between the abandoned compartment 2NW and compartment A a designated smoke compartment separation contains a door with a delayed egress. This smoke barrier does not comply with 19.2.4.4 due to the following:
1. The delayed egress door is locked against egress from compartment 2NW into compartment A.
2. Staff did not carry a key to readily unlock doors at all times 19.2.2.2.6(1), (2) and (3).

Based on observation, not all stair components used within an exit stair are constructed to comply with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings are:

A. On 02/02/2022 at 10:10am while accompanied by the D.F.O., Basement level Exit Stair #11 is arranged to continue from the basement to exit on the main level. The stair serves as a required exit for Compartment D. This required exit stair does not comply with 19.2.2.3 due to the following:

1. This stair contains an elevator which serves the basement through second floors. This condition does not comply with 19.2.2.3, 7.2.2.5, 7.1.3.2.1(9), (10) and 7.1.3.2.3 for the sole use of an exit enclosure.

2. This stair contains a conduit on the basement level that does not serve the stair. This condition does not comply with 7.1.3.2.1(10).

B. On 02/02/2022 at 10:20am while accompanied by the D.F.O., Basement level Exit Stair #1 contains a med/vac conduit which does not comply with 7.1.3.2.1.

Based on observation, exit stairs were not readily accessible at all times. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. On 02/01/2022 at 10:30am, Mental Health Unit on the 2nd Floor east end compartment A, while accompanied by the D. F.O.surveyor observed an exit door (directly leads to Exit Stair) , which is was equipped with a disconnectedmagnetic locking device. The door frame contains a large hole in the fire rated enclosure which does not comply with 19.2.2.5.

B. On 02/01/2022 at 10:45am, Mental Health Unit on the 2nd Floor accompanied by the D. F.O., the surveyor observed Exit Stair doors, which are equipped with keyed hardware to which staff do not have a readily available key at all times to unlock exit doors. This does not comply with 19.2.2.2.2 Exception No. 2. Locations observed:
1. Compartment 2NW(abandoned) north end Exit Stair
2. East side of Compartment A, Exit Stair

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition.

On 02/02/2022 at 10:48am accompanied by the D.F.O. a corridor in smoke compartment D, basement level, lacks exit signage leading to exit stair #11. This condition does not comply with 19.2.4.4.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Finding includes:

On 02/01/2022, at 11:26am while accompanied by the D.F.O., observation determined that doors to hazardous areas are not self closing to comply with 19.3.2.1.3. Location observed: Third floor O.R. Storage room door contains a manual hold open.

Based on observation smoke detectors are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation during an emergency. If devices do not function properly, then building occupants may not be alerted to an emergency in a timely manner.

The finding is:

It was observed at various locations that detectors are located where airflow may prevent normal operation of the device as written in NFPA 72-2012 17.7.4.1. Locations & conditions observed include the following:

1. On 02/01/2022 at 12:10pm, accompanied by the D.F.O. a smoke detector was observed within 3"-0" of an HVAC diffuser. Location observed: Third floor corridor across from room #312.

Based on observation the facility lacks complete sprinkler protection. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 02/01/2022 , accompanied by the D.F.O. sprinkler heads are not installed to comply with NFPA 13, 2010, 26.2. locations observed:

1. At 11:15am, Third floor Mechanical Room "F" below the ductwork.

2. At 2:25pm, Basement landing for Exit Stair #4

Based upon observation, corridors do not form a smoke tight separation from use areas. This deficient practice could affect patients, staff and visitors if a failure at a corridor wall provides the migration of a fire/smoke from one side of the wall to the other thus compromising the safe egress of occupants.

The finding is:

On 02/01/2022 at 1:40pm while accompanied by the D.F.O. it was observed that the Second floor Nuclear Medicine suite contains metal lockers semi-recessd in a wall with a continuous gap present between the lockers and the wall. This condition does not comply with 19.3.6.2.2 and 19.3.6.2.3.

Based upon review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

Finding includes:

On 02/02/2022 at 9:30am accompanied by the D.F.O., documentation for fire rated doors was reviewed. The following information was not available:
There is no indication a complete fire door inspection was conducted for 2021 pertaining to the Building in order to comply with 7.2.1.15.3, 7.2.1.15.7 and 7.2.1.15.8 due to the following:

1. There is no indication that damaged doors and components have been repaired or replaced (7.2.1.15.8).

2. There is no indication that the inspector is aware of the specific components assigned to each door's function (7.2.1.15.5).

Based on observation, not all portions of the building electrical system are installed in accordance with the code. These deficiencies could affect any or all patient care areas, due to electrical power is unavailable for their treatment.

The finding is:

On 02/01/2022 at 3:00pm while accompanied by the D.F.O. a medical surgical room on the main level was found not to be installed with alternate source of power (emergency outlets) tied to the Emergency Generator, to comply with NFPA 70, 2011 517-18(a). Location observed: Room #117

Based on observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

On 02/01/2022at 12:00pm, accompanied by the D.F.O it was observed in the Third floor ICU that a drinking fountain is plugged directly into a receptacle which is less than 6'-0" and not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(5).