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Based on observations, the facility failed to properly separate multiple sections of health care facilities in accordance NFPA 101 sections 19.1.3.2 and 19.1.3.3. The deficient practice affected the entire facility on day of survey.


Findings include:

During the building inspection on November 11, 2019 at 11:05 AM, observation revealed a health clinic (business occupancy) not properly separated by a rated 2-hour fire wall and doors from the hospital. Observation also revealed the clinic served public and was leased to private company.

Based on observation and interviews, the facility failed to properly maintain exit egress as per NFPA 101 section 19.2.2.2.6. The deficient practice affected the entire facility on day of survey.

Findings include:

On November 11, 2019 at 10:40 AM, observation revealed a partition obstructing and blocking the hallway mean of egress from the Behavioral Unit near the Clinic Area of the facility.

Based on observation, the facility failed to properly maintain exit egress as directed by NFPA 101 section 19 2.2.2.4. The deficient practice affected the entire facility on day of survey.


Findings include:

On November 11, 2019 at 1:55 PM, observations revealed the following exit door deficiencies of the facility:

1. The exit door of the Behavioral Unit had a double keyed dead bold
2. The exit doors of the Activity Office, Shower and Behavioral Supervisor's Office had hasps locks.
3. The exit door from the Behavioral Unit was blocked and would not open creating a dead-end corridor
4. The magnetic locks on exit door in the Clinic Area did not release and open upon activation of the fire alarm system

Based on observations, the facility failed to properly protect hazardous areas in accordance to NFPA 101 section 19.3.2.1. The deficient practice affected the entire facility on day of survey.

Findings include:

During the building inspection on November 11, 2019 between 9:40 AM and 10:40 AM, observation revealed deficiencies in the following hazardous areas of the facility:

1) Unsealed openings and penetrations in the ceiling and walls of the HVAC Closet on the Human Resource
Hallway of the facility
2) Unsealed openings and penetrations in the ceilings of the Computer Closet, Old Kitchen, Cat Scan, and Old X-Ray
3) The Housekeeping Storage area was open to the main corridor of the facility (Missing corridor door)

These hazardous areas were incapable of resisting the passage of smoke throughout the facility.

Based on observation, the facility failed to properly maintain the fire alarm system in accordance to NFPA 72. Based on record review, the facility failed to properly perform fire drills as per NFPA 19 .7.1.2. The deficient practice affected the entire facility on day of survey.


Findings include:

During testing of the fire alarm system on November 11, 2019 at 9:30 am, observation revealed a "trouble" signal on the panel of the fire alarm. The maintenance director was unable to diagnosis and reset the fire alarm system to "normal" status. The fire alarm system was still functioning correctly and was able to notify emergency services.

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building as required by NFPA 101 section 19.3.5.1. The deficient practice affected the entire facility on day of survey.


Findings include:

On November 11, 2019 at 10:05AM, observation revealed no fire sprinkler protection in the Riser Room of the facility. The Riser Room was unsprinkled.

Based on record review and interviews with staff, the facility failed to properly insure the operability of the
sprinkler system as required by NFPA 25 Table 2-1 and section 2-2.6. The deficient practice affected the entire facility on day of survey.


Findings include:

On November 11, 2019 at 2:10 PM, the facility could not provide documentation of a quarterly inspection of the sprinkler system for the 4th quarter of 2018 and for the 1st and 2nd quarters of 2019. The same deficiency was cited on 2016 Life Safety Code survey.

Based on observations and interviews, the facility failed to properly inspect fire extinguishers as per NFPA 10 sections 7.3.1.2.1, 7.3.3.2 and 7.3.1.1.2. The deficient practice affected the entire facility on day of survey.

Findings include:
On November 11, 2019 12:45 PM, observation revealed the K Class fire extinguisher in the Kitchen had not received a six-year inspection. The K Class fire extinguisher was last inspection in the calendar year 2012.

Based on observation and testing, the facility failed to properly protect corridor openings as directed by NFPA 101 sections 19.3.6.3.5 and 19.3.6.3.13. The deficient practice affected the entire facility on day of survey.

Findings include:

On November 11, 2019 between 9:35 AM and 10:55 AM, observation revealed no lacked door knobs on the corridor doors to Patient Rooms 12, 19, 21, and 23 of the facility. Observation also revealed the doors to the old Emergency Room and Shower Room of the Behavioral Unit lacked positive latching devices.

On November 11, 2019 at 10:25 AM, observation also revealed no positive latching on the top leaf of the Dutch doors to the Medical Records Office, old X Ray Room, and Social Worker Office of the facility.

Based on observation, the facility failed to properly protect corridor openings as directed by NFPA 101 section 19.3.6.4.1. The deficient practice affected the entire facility on day of survey.

Findings include:

On November 11, 2019 at 11:00 AM, observation revealed an air transfer grille in the (corridor) door to the Electrical Closet near Purchasing Office of the facility. The door to the Electrical Closet was incapable of resisting the passage of smoke throughout the facility.

Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing one (1) half hour fire resistance as directed by NFPA 101 section 8.5.6. The deficient practice affected the entire facility on day of survey.

Findings include:

On November 11, 2019 at 1:10 PM, observation revealed numerous unsealed penetrations in the smoke barrier walls of the facility. The smoke barrier walls were located above the lay-in ceiling tiles at the Main Mechanical Room and at the Behavioral Unit of the facility.

Based on observations and testing, the facility failed to properly maintain door openings in smoke barrier walls as per NFPA 101 section 19.3.7.8. The deficient practice affected the entire facility on day of survey.

Findings include:

On November 11, 2018 at 12:00 P.M., observation revealed a wedge obstructing the smoke barrier door near the Clinic Area of the facility.

Based on record review, the facility failed to properly perform fire drills as per NFPA 19 .7.1.2. The deficient practice affected the entire facility on day of survey.


Findings include:

During document review on November 11, 2019 at 1:20 PM, the facility could not provide documentation of a fire drills conducted on any work shifts during the last calendar year of 2019.

Based on document review, the facility failed to properly test the emergency generator as per NFPA 110 section 8.4.2. The deficient practice affected the entire facility on day of survey.

Findings include:

During document review on November 11, 2019 at 2:12 PM, the facility could not provide documentation showing the weekly inspections, monthly load tests, and certified annual inspection for the generator during the last calendar year of 2019.