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Based on observation, the facility failed to ensure no impediment to closure of a fire rated door. This was evidenced by an object wedged at the bottom of the self closing door. This failure affected the waiting area/lobby, and had the potential to allow the spread of smoke in the event of a fire.

Findings:

During a tour of the facility with Operations Staff 1 on 10/27/15, the doors equipped with self closing devices were observed.

Outpatient Building
At 9:00 a.m., there was a door to the galley equipped with a self closing device that had a folded piece of cardboard wedged at the bottom preventing the door from self closing.

Based on observation, the facility failed to maintain their fire barrier doors. This was evidenced by holes in a fire rated door. This failure affected 1 of 3 smoke compartments and had the potential to decrease the fire resistance of the door there by increasing the potential for harm to staff on residents..

Findings:

During a tour of the facility with operations Staff 1 on 10/27/15, the fire rated doors were observed.

At 9:38 a.m., there was a door located in the corridor by the staff locker rooms that had two holes approximately one half inch round in the upper left corner where a closing device was removed or adjusted.

Based on observation and interview, the facility failed to ensure that staff had on their person the proper tools or equipment to activate the fire alarm system. This was evidenced by staff not having the key to activate the manual fire alarm stations. This failure affected 2 of 2 smoke compartments and had the potential to delay the notification and evacuation of residents in the event of a fire.

Findings:

ADOL 2nd Floor
During a tour of the facility with Operations Staff 1 on 10/27/15, the activation of the manual alarms was observed.

At 10:10 a.m., staff were not equipped with keys to activate the manual alarm station on the second floor. Operations Staff 1 stated the keys were made but not yet assigned to all staff members. Operations Staff 1 stated and identified the key to activate the fire alarm was located at the nurses station.

Based on observation, the facility failed to maintain their sprinkler system as evidenced by a missing escutcheon ring. This affected 1 of 3 smoke compartments on the first floor and could result in the spread of smoke in the event of a fire.

Findings:

NFPA 101, Life Safety Code 2000 Edition.
19.7.6 Maintenance and Testing. (See 4.6.12.)
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 13, 1999 Edition. Standard for the Installation of Sprinkler Systems.
3-2.7 Escutcheon Plates.
3-2.7.1 Nonmetallic escutcheon plates shall be listed.
3-2.7.2* Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

During a tour of the facility with Operations Staff 1 on 10/26/15, the sprinkler assemblies were observed.

PICU 10/26/15
At 2:20 p.m., there was a sprinkler in the elevator mechanical room that was missing the escutcheon ring creating a two inch penetration in the ceiling.

Based on observation, the facility failed to ensure no impediment to closure of a fire rated door. This was evidenced by an object wedged at the bottom of the self closing door. This failure affected the waiting area/lobby, and had the potential to allow the spread of smoke in the event of a fire.

Findings:

During a tour of the facility with Operations Staff 1 on 10/27/15, the doors equipped with self closing devices were observed.

Outpatient Building
At 9:00 a.m., there was a door to the galley equipped with a self closing device that had a folded piece of cardboard wedged at the bottom preventing the door from self closing.

Based on observation, the facility failed to maintain their fire barrier doors. This was evidenced by holes in a fire rated door. This failure affected 1 of 3 smoke compartments and had the potential to decrease the fire resistance of the door there by increasing the potential for harm to staff on residents..

Findings:

During a tour of the facility with operations Staff 1 on 10/27/15, the fire rated doors were observed.

At 9:38 a.m., there was a door located in the corridor by the staff locker rooms that had two holes approximately one half inch round in the upper left corner where a closing device was removed or adjusted.

Based on observation and interview, the facility failed to ensure that staff had on their person the proper tools or equipment to activate the fire alarm system. This was evidenced by staff not having the key to activate the manual fire alarm stations. This failure affected 2 of 2 smoke compartments and had the potential to delay the notification and evacuation of residents in the event of a fire.

Findings:

ADOL 2nd Floor
During a tour of the facility with Operations Staff 1 on 10/27/15, the activation of the manual alarms was observed.

At 10:10 a.m., staff were not equipped with keys to activate the manual alarm station on the second floor. Operations Staff 1 stated the keys were made but not yet assigned to all staff members. Operations Staff 1 stated and identified the key to activate the fire alarm was located at the nurses station.

Based on observation, the facility failed to maintain their sprinkler system as evidenced by a missing escutcheon ring. This affected 1 of 3 smoke compartments on the first floor and could result in the spread of smoke in the event of a fire.

Findings:

NFPA 101, Life Safety Code 2000 Edition.
19.7.6 Maintenance and Testing. (See 4.6.12.)
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 13, 1999 Edition. Standard for the Installation of Sprinkler Systems.
3-2.7 Escutcheon Plates.
3-2.7.1 Nonmetallic escutcheon plates shall be listed.
3-2.7.2* Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

During a tour of the facility with Operations Staff 1 on 10/26/15, the sprinkler assemblies were observed.

PICU 10/26/15
At 2:20 p.m., there was a sprinkler in the elevator mechanical room that was missing the escutcheon ring creating a two inch penetration in the ceiling.