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Building A-5 (also known as Building #121-Geriatrics)

Through observation during the survey, May 11 through May 17, 2010, it was determined that the facility failed to maintain the two-hour fire resistance rating of the common wall between the Hospital and other facilities

During the walk through of the facility with the Maintenance and Operations Manager, the two-hour separation, in building #121, contained a door frame fire rating of ninety minutes (90) hours, however, the doors were rated at a forty-five (45) minute fire rating. This was evidence by the metal door frame tags located on the door and frame.

Building A-6 (also known as Building #127-Advanced Cottages)

Through observation during the survey, conducted on May 11 through May 17, 2010, it was determined that the facility had not maintained the interior finish of the corridor ceilings.

During the walk through and record review with the Maintenance and Operations Manager, the ceiling in finish in building #127 contained a wood finish of wainscoting. The wainscot finish was located in the egress corridor, living room, kitchen and dining room of the building, which are all open and not separated to the egress corridor. The fire spread rating documentation was not available showing a class A or class B flame spread rating. Per NFPA 101 2000 Edition, Chapter 19, section 19.3.3.2.

Building A-1 (also known as Building #106-Community reintegration Unit)

Through observation during the survey, May 11 through May 17, 2010, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance and Operations Manager:
A) Eight (8) resident room doors in Building #106 contained gaps larger than 1/2" between the door and the doorstop, which would not maintain a positive smoke seal.
1) B017
2) B024
3) B025
4) B054
5) B055
6) C023
7) C051
8) C055
B) Room #C017 in building #106 contained two (2) small holes in the door around the window. The holes were located at the middle attachment bolts for the window.

Building A-5 (also known as Building #121-Geriatrics)

Through observation during the survey, May 11 through May 17, 2010, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance and Operations Manager, resident room door #B025 in Building #121 contained gaps larger than 1/2" between the door and the doorstop, which would not maintain a positive smoke seal.

Building A-6 (also known as Building #127-Advanced Cottages)

Through observation during the survey, May 11 through May 17, 2010, it was determined that the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility with the Maintenance and Operations Manager:
1) The pantry closet in the kitchen, located in building #127, did not contain sprinkler coverage. The closet contained doors and a lintel depth of over twelve inches (12").
2) The sprinkler system in building #127 did not contain sprinkler gauges at the riser per NFPA 13.
Note: This sprinkler gauges were replaced by maintenance during the survey.

Building A-7 (also known as Building #137-Locked Adolescent Unit)

Through observation during the survey, May 11 through 17, 2010, it was determined the facility failed to maintain the automatic sprinkler system per NFPA 25.

During the walk through of the facility with the Maintenance and Operations Manager, documentation was not available to verify a sprinkler gauge calibration or replacement occurred every five (5) years per NFPA 25. Two (2) sprinkler gauges, located in building #137, contained manufacturer dates of 1997. 1999 Edition of NFPA 25, section 2-3.2.
Note: The gauges were replaced by maintenance staff during the survey.

Building A-2 (also known as Building #115-Circle Unit)

Through record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed to service the kitchen hood suppression system.

During the review of the facility records and observation with the Maintenance and Operations Manager, the annual testing documentation, dated 2008, on the kitchen hood system, for building #115, stated that the hydrostatic test of the kitchen hood system tank needed to be completed. Documentation could not be located stating that the hydrostatic test had been completed. There also was no indication on the tank showing that a hydrostatic test had been completed. NFPA 101 2000 Edition, Chapter 19, section 19.3.2.6, section 9.2.3, NFPA 96, section 7-2.2.1, and NFPA 17, section 9-5.

Building A-3 (also known as Building #116-Ward 67 and Ward 69)

Through record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed to service the kitchen hood suppression system.

During the review of the facility records and observation with the Maintenance and Operations Manager, the annual testing documentation, dated 2008, on the kitchen hood system, for building #116, stated that the hydrostatic test of the kitchen hood system tank needed to be completed. Documentation could not be located stating that the hydrostatic test had been completed. There also was no indication on the tank showing that a hydrostatic test had been completed. NFPA 101 2000 Edition, Chapter 19, section 19.3.2.6, section 9.2.3, NFPA 96, section 7-2.2.1, and NFPA 17, section 9-5.

Building A-1 (also known as Building #106-Community reintegration Unit)

Through observation during the survey, May 11 through May 17, 2010, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walk through of the facility with the Maintenance and Operations Manager, building #106 contained three (3) floor fans that were plugged into the wall and stored in the corridor.
Note: The fans were removed by staff during the survey.

Building A-2 (also known as Building #115-Circle Unit)

Through observation during the survey, May 11 through May 17, 2010, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walk through of the facility with the Maintenance and Operations Manager, building #115, contained two (2) water fountains installed side by side in two (2) areas that projected eighteen inches (18") into the corridor. Per NFPA 101 2000 Edition, Chapter 7, section 7.1.10, "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use."

Building A-4 (also known as Building #120-Adult Cognitive Behavioral Unit)

Through observation during the survey, May 11 through May 17, 2010, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walk through of the facility with the Maintenance and Operations Manager, building #120 contained items stored in the corridor in two (2) areas;
1) Two (2) plants and a couch located in the corridor outside room #C010.
2) One couch located and stored in the corridor outside #C046A. Per NFPA 101 2000 Edition, Chapter 7, section 7.1.10, "Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use."
Note: All items moved during survey by staff.

Building A-1 (also known as Building #106-Community reintegration Unit)

Through observation and record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility with the Maintenance and Operations Manager, documentation was not available to indicate that all draperies located throughout building #106 met NFPA 701 standards for flame resistance. NFPA 101 2000 Edition, section 19.7.5.1, section 10.3.1 and NFPA 701.

Building A-2 (also known as Building #115-Circle Unit)

Through observation and record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility with the Maintenance and Operations Manager, documentation was not available to indicate that all draperies located throughout building #115 met NFPA 701 standards for flame resistance. NFPA 101 2000 Edition, section 19.7.5.1, section 10.3.1 and NFPA 701.

Building A-3 (also known as Building #116-Ward 67 and Ward 69)

Through observation and record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility with the Maintenance and Operations Manager, documentation was not available to indicate that all draperies located throughout building #116 met NFPA 701 standards for flame resistance. NFPA 101 2000 Edition, section 19.7.5.1, section 10.3.1 and NFPA 701.

Building A-4 (also known as Building #120-Adult Cognitive Behavioral Unit)

Through observation and record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility with the Maintenance and Operations Manager, documentation was not available to indicate that all draperies located throughout building #120 met NFPA 701 standards for flame resistance. NFPA 101 2000 Edition, section 19.7.5.1, section 10.3.1 and NFPA 701.

Building A-5 (also known as Building #121-Geriatrics)

Through observation and record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility with the Maintenance and Operations Manager, documentation was not available to indicate that all draperies located throughout building #121 met NFPA 701 standards for flame resistance. NFPA 101 2000 Edition, section 19.7.5.1, section 10.3.1 and NFPA 701.

Building A-6 (also known as Building #127-Advanced Cottages)

Through observation and record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility with the Maintenance and Operations Manager, documentation was not available to indicate that all draperies located throughout building #127 met NFPA 701 standards for flame resistance. NFPA 101 2000 Edition, section 19.7.5.1, section 10.3.1 and NFPA 701.

Building A-7 (also known as Building #137-Locked Adolescent Unit)

Through observation and record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility with the Maintenance and Operations Manager, documentation was not available to indicate that all draperies located throughout building #137 met NFPA 701 standards for flame resistance. NFPA 101 2000 Edition, section 19.7.5.1, section 10.3.1 and NFPA 701.

Building A-1 (also known as Building #106-Community reintegration Unit)

Through observation during the survey, conducted May 11 through May 17, 2010, it was determined that the facility failed to maintain the oxygen storage/transfer room.

During the walk through of the facility with the Maintenance and Operations Manager, building #106 contained two (2) rooms with one (1) liquid oxygen tank in each rooms. During conversations with the nursing staff, they do oxygen transfer from the liquid oxygen tank into portable tanks for residents in these "Med Rooms."
1) The rooms did not contain sprinkler protection.
2) The rooms did not contain mechanical ventilation.
3) The rooms contained a 20 minute rated door.
Per NFPA 99, section 8-6.2.5.2 Transferring Liquid Oxygen. Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of one-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.

Building A-3 (also known as Building #116-Ward 67 and Ward 69)

Through observation during the survey, conducted May 11 through May 17, 2010, it was determined that the facility failed to maintain the oxygen storage/transfer room.

During the walk through of the facility with the Maintenance and Operations Manager, building #116 contained two (2) rooms with one (1) liquid oxygen tank in each rooms (one room on the first (1st) floor and one room on the second (2nd) floor). During conversations with the nursing staff, they do oxygen transfer from the liquid oxygen tank into portable tanks for residents in these "Med Rooms."
1) The rooms did not contain sprinkler protection.
2) The rooms contained VCT flooring.
3) The rooms contained a 20 minute rated door.
Per NFPA 99, section 8-6.2.5.2 Transferring Liquid Oxygen. Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of one-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.

Building A-5 (also known as Building #121-Geriatrics)

Through observation during the survey, conducted May 11 through May 17, 2010, it was determined that the facility failed to maintain the oxygen storage/transfer room.

During the walk through of the facility with the Maintenance and Operations Manager, building #121 contained two (2) rooms with one (1) liquid oxygen tank in each rooms. During conversations with the nursing staff, they do oxygen transfer from the liquid oxygen tank into portable tanks for residents in these "Med Rooms."
1) The rooms did not contain sprinkler protection.
2) The rooms did not contain mechanical ventilation.
3) The rooms contained a 20 minute rated door.
Per NFPA 99, section 8-6.2.5.2 Transferring Liquid Oxygen. Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and
(b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and
(c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.

Building A-6 (also known as Building #127-Advanced Cottages)

Through record review during the survey, May 11 through May 17, 2010, it was determined that the facility failed document the generator exhaust temperature during the thirty (30) minute test monthly.

During the review of the facility records with the Maintenance and Operations Manager, documentation for the generator testing of building #127, did not indicate the exhaust gas temperature readings for the testing dates of July 14, 2009, November 12, 2009, February 10, 2010, and April 14, 2010. The facility measures the exhaust gas temperature instead of the amperage readings for the monthly tests as stipulated by NFPA 110 1999 Edition, section 6-4.2.