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Based on observation and staff interview, the facility failed to maintain the smoke resistance of 1 cooridor door according to NFPA 101 LSC (00) section 19.3.6.3.2. This deficient practice could affect the safety of patients, staff and visitors, if smoke from a fire were allowed to enter the exit access corridors making it untenable.

Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 observations and staff interview revealed a corridor closet in the 1997 addition did not positively latch.

This deficient condition was verified by the Director of Facility Operations.

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient condition could in the event of a fire, allow smoke and flames to spread throughout the corridor and adjacent areas making them untenable, which could negatively affect the exiting capabilities for patients, staff and visitors.


Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 observations and staff interview revealed a closer missing from a storage room door located in the link to the 1997 addition.

This deficient condition was verified by the Director of Facility Operations.

Based on documentation review and staff interview, it was determined that the facility failed to conduct fire drills in accordance with NFPA Life Safety Code 101(00), 19.7.1.2, during the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, staff and visitors

Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 record review and staff interview revealed fire drills were not being conducted during one shift per quarter.

This deficient condition was verified by the Director of Facility Operations.

Based on documentation review and interview with staff, the facility has failed to properly maintain the automatic sprinkler system in accordance with NFPA 101 Life Safety Code (00), Section 19.7.6, and 4.6.12, NFPA 13 Installation of Sprinkler Systems (99), and NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, (98). This deficient practice does not ensure that the proper sprinkler head would be replaced and the fire sprinkler system would function properly in the event of a fire and could negatively affect, all patients, staff and visitors.

Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 observations and staff interview revealed the proper sprinkler heads were not stored in the head box, 2 quick response heads were missing.

This deficient condition was verified by the Director of Facility Operations.

Based on review of records and staff interview, the facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110 - 1999 edition and NFPA 99 - 1999 edition, section 3-4.1.1.2. This deficient practice does not ensure the generator could support the necessary systems in case of a power outage and could affect the safety of all patients, staff and visitors.


Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 record review and staff interview revealed the generator load test could not meet the 30% of the generator rating and the cool down cycle was not being monitored and logged.

This deficient condition was verified by the Director of Facility Operations.


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Based on observations and staff interview the facility failed to maintain the facilitys electrical wiring per NFPA 101 (99) section 9.1.2 and NFPA 70. This deficient practice could affet all patients, staff and visitors.

Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 observations and staff interview revealed a permanent wired electrical box was hanging loosely under the staff counter in the reception area.

This deficient condition was verified by the Director of Facility Operations.

Based on observation and staff interview, the facility failed to maintain the smoke resistance of 1 cooridor door according to NFPA 101 LSC (00) section 19.3.6.3.2. This deficient practice could affect the safety of patients, staff and visitors, if smoke from a fire were allowed to enter the exit access corridors making it untenable.

Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 observations and staff interview revealed a corridor closet in the 1997 addition did not positively latch.

This deficient condition was verified by the Director of Facility Operations.

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient condition could in the event of a fire, allow smoke and flames to spread throughout the corridor and adjacent areas making them untenable, which could negatively affect the exiting capabilities for patients, staff and visitors.


Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 observations and staff interview revealed a closer missing from a storage room door located in the link to the 1997 addition.

This deficient condition was verified by the Director of Facility Operations.

Based on documentation review and staff interview, it was determined that the facility failed to conduct fire drills in accordance with NFPA Life Safety Code 101(00), 19.7.1.2, during the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, staff and visitors

Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 record review and staff interview revealed fire drills were not being conducted during one shift per quarter.

This deficient condition was verified by the Director of Facility Operations.

Based on documentation review and interview with staff, the facility has failed to properly maintain the automatic sprinkler system in accordance with NFPA 101 Life Safety Code (00), Section 19.7.6, and 4.6.12, NFPA 13 Installation of Sprinkler Systems (99), and NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, (98). This deficient practice does not ensure that the proper sprinkler head would be replaced and the fire sprinkler system would function properly in the event of a fire and could negatively affect, all patients, staff and visitors.

Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 observations and staff interview revealed the proper sprinkler heads were not stored in the head box, 2 quick response heads were missing.

This deficient condition was verified by the Director of Facility Operations.

Based on review of records and staff interview, the facility failed to maintain the emergency generator in accordance with the requirements of NFPA 110 - 1999 edition and NFPA 99 - 1999 edition, section 3-4.1.1.2. This deficient practice does not ensure the generator could support the necessary systems in case of a power outage and could affect the safety of all patients, staff and visitors.


Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 record review and staff interview revealed the generator load test could not meet the 30% of the generator rating and the cool down cycle was not being monitored and logged.

This deficient condition was verified by the Director of Facility Operations.


.

Based on observations and staff interview the facility failed to maintain the facilitys electrical wiring per NFPA 101 (99) section 9.1.2 and NFPA 70. This deficient practice could affet all patients, staff and visitors.

Findings include:

On the facility tour between 8:30 am to 2:00 pm on 08/09/2016 observations and staff interview revealed a permanent wired electrical box was hanging loosely under the staff counter in the reception area.

This deficient condition was verified by the Director of Facility Operations.