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Based upon observation and interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could affect 28 occupants in the event of required protection of the room and surrounding rooms per the construction of the building and the life safety plans.

Findings Include:
On 12-11-17 at approximately 10:00 AM the following observations were made:

At approximately 10:58AM - While on tour with the Facility Plant Operations Manager observed in In-Processing Building the CORRIDOR DOOR TO RECORDS was wedged in the open position. This door is a 90 minute fire door, and per the life safety drawings protects a 1 hour rated room.

At Approximately 11:52 AM - While on tour with the Facility Plant Operations Manager observed in the KITCHEN, the fire door in the SMOKE BARRIER WALL separating the KITCHEN and the DRY PANTRY was wedged in the open position.

All observations were confirmed by the manager of Plant Operations.

Based upon observation and interview, the facility failed to ensure that the width of aisles or corridors was maintained clear and unobstructed in accordance with 19.2.3.4 and 19.2.3.5. This deficient practice could affect 76 occupants in the event of evacuation of the facility.

Findings Include:
On 12-11-17 at approximately 10:00AM the following observations were made:

At approximately 12:25PM - While on tour of the facility with the Plant Operation Manager observed in the corridor of the ADOLESCENT WING near the SUPPLIES CLOSET, a Soiled laundry cart stored in the corridor.

All observations were confirmed by the Plant operations manager.

Based upon observation and interview, the facility failed to ensure that the width of aisles or corridors was maintained clear and unobstructed in accordance with 19.2.3.4 and 19.2.3.5. This deficient practice could affect 76 occupants in the event of evacuation of the facility.

Findings Include:
On 12-11-17 at approximately 11:00AM the following observations were made:

At approximately 11:46AM - While on tour of the facility with the Plant Operation Manager, observed in the corridor near the KITCHEN and the ELECTRICAL ROOM combustible storage in the corridor. This corridor is in the same smoke compartment as the ADULT WING and is separated only by security doors.

At approximately 12:25PM - While on tour of the facility with the Plant Operation Manager, observed in the corridor of the ADOLESCENT WING near the SUPPLIES CLOSET a Soiled laundry cart stored in the corridor.

All observations were confirmed by the Plant Operations Manager.

Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect all occupants in the event of required protection of the room and surrounding rooms per the construction of the building and the life safety plans.

Findings Include:
On 12-11-17 at approximately 10:00AM the following observations were made:

At Approximately 11:02AM - While on tour with the Facility Plant Operations Manager observed above ceiling in the RECORDS ROOM located in the INPROCESSING BUILDING, a penetration above the corridor door above the duct of a gap that was not fire stopped per the rating in the life safety drawings.

All observations were confirmed by the Manager of Plant Operations.

Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect All occupants in the event of use of the fire suppression system.

Findings Include:
On 12-11-17 at approximately 10:00AM the following observations were made:

At Approximately 10:50AM - While on tour with the Facility Plant Manager observed in the CONFERENCE ROOM a ceiling tile removed.

At Approximately 11:11AM - While on tour with the Facility Plant Manager observed in the TIME CLOCK HALL near MARKETING OFFICE a sprinkler head that is painted.

All observations of deficiencies were confirmed by the Facility Plant Manager.

Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect all occupants in the event of use of the fire suppression system.

Findings Include:
On 12-11-17 at approximately 10:00AM the following observations were made:

At Approximately 11:53AM - While on tour with the Facility Plant Manager observed in the KITCHEN, sprinkler heads were excessively dirty and require cleaning.

All observations of deficiencies were confirmed by the Facility Plant Manager.

Based upon observation and interview, the facility failed to ensure that portable fire extinguishers are selected, installed, inspected and maintained in accordance with NFPA 10 as required by 19.3.5.12. This deficient practice could affect all occupants in the event of the need to use the fire extinguisher in a fire emergency.

Findings Include:
On 12-11-17 at approximately 10:00AM the following observations were made:

At Approximately 11:51AM - While on tour of the facility with the Plant Operation Manager observed in the KITCHEN near the DRY PANTRY, a fire extinguisher with its safety pin pulled and the seal broken.

All observations were confirmed by the Plant Operations Manager.

Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect 28 occupants in the event of evacuation of the facility.

Findings Include:
On 12-11-17 at approximately 10:00AM the following observations were made:

At Approximately 10:48AM - While on tour with the Facilities Plant Manager observed in the INPROCESSING BUILDING the corridor door separating the front offices and the waiting area two holes through the door above the handle.

At Approximately 10:49AM - While on tour with the Facilities Plant Manager observed the CORRIDOR DOOR to INTAKE OFFICE was wrapped in Christmas wrapping paper and wrapped around the edges of the door.

All observation of deficiencies were confirmed by the Facility Plant Manager.

Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect all occupants in the event of evacuation of the facility.

Findings Include:
On 12-11-17 at approximately 10:00AM the following observations were made:

At Approximately 12:37PM - While on tour with the Facilities Plant Manager in the ADOLESCENT WING observed the CORRIODR DOOR to ROOM #9 could not close to a positive latch. The door was also cracked exposing the inner part of the door from a patient and could not provide a smoke tight seal.

All observation of deficiences were confirmed by the Facility Plant Manager.

Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect all occupants in the event of evacuation of the facility.

Findings Include:
On 12-11-17 at approximately 11:00AM the following observations were made:

At Approximately 11:17AM - While on tour with the Facilities Plant Manager observed the CORRIDOR DOOR to room #25 wrapped in Christmas wrapping paper which wrapped around to the edges of the door.

At Approximately 11:21AM - While on tour with the Facilities Plant Manager observed the CORRIDOR DOOR to OFFICE #26 wrapped in Christmas wrapping paper and wrapped around the edges of the door.

At Approximately 11:31AM - While on tour with the Facilities Plant Manager observed the CORRIDOR DOOR to OFFICE #30 wrapped in Christmas wrapping paper and wrapped around the edges of the door.

At Approximately 11:32AM - While on tour with the Facilities Plant Manager observed the CORRIDOR DOOR to OFFICE #29 wrapped in Christmas wrapping paper and wrapped around the edges of the door.

At Approximately 11:41AM - While on tour with the Facilities Plant Manager observed the CORRIDOR DOOR to CHEMICAL DEPENDENT UNIT MANAGERS OFFICE wrapped in Christmas wrapping paper and wrapped around the edges of the door.

At Approximately 11:42AM - While on tour with the Facilities Pant Manager observed the CORRIDOR DOOR to SOCIAL WORK OFFICE wrapped in Christmas wrapping paper and wrapped around the edges of the door.

At Approximately 12:00PM - While on tour with the Facilities Plant Manager observed the CORRIDOR DOOR to the KITCHEN SERVING LINE was not properly sealed. At the top of the door was a gap on the latching side.

At Approximately 12:03PM - While on tour with the Facilities Plant Manager observed the CORRIDOR DOOR too the ADULT WING TV (television) ROOM had the large glass with frame removed exposing the inner portion of the door. During questioning of the Facilities Plant Manager it was relayed a patient had broken the window and a replacement was on order.

At Approximately 12:06PM - While on tour with the Facilities Plant Manager observed the CORRIDOR DOOR to ROOM #6 could not close to a positive latch. The door was also cracked and could not provide a smoke tight seal.

At Approximately 12:12PM - While on tour with the Facilities Plant Manager observed in the SENIOR ADULT WING ROOM #6 was not properly sealed at the top of the door. A gap showed upon closing the door on the latch side.

At Approximately 12:15PM - While on tour with the Facilities Plant Manager observed SEVERAL RESIDENT ROOM DOORS with LINEN CLOTHS hanging over the door. During questioning of the UNIT MANAGER it was discovered the cloths were put there by staff to prevent the doors from making loud noises when they were closed. The cloths in some cases prevented the doors from closing to a positive latch at all.

At Approximately 12:37PM - While on tour with the facilities plant manager in the ADOLESCENT WING observed the CORRIDOR DOOR to ROOM #9 could not close to a positive latch. The door was also cracked exposing the inner part of the door and could not provide a smoke tight seal.

All observation of deficiencies were confirmed by the Facility Plant Manager.

Based upon observation and interview, the facility failed to ensure that smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5 as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect All occupants in the event of required protection of the room and surrounding reooms per the construction of the building and the life safety plans.

Findings Include:
On 12-11-17 at approximately 10:30AM the following was observed:

At Approximately 12:45PM - While on tour with the Facility Plant Manager observed above ceiling at the 2 hour barrier wall seperating the ADOLESCENT WING and the AUTISM WING a penetration of a flex conduit not fire stopped.

All observations of deficiencies were confirmed by the Facility Plant Manager.

Based upon observation, records review and interview, the facility failed to ensure that smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5 as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect all occupants in the event of required protection of the room and surrounding rooms per the construction of the building and the life safety plans.

Findings Include:
On 12-11-17 at approximately 10:30AM the following was observed:

At Approximately 10:45AM - Observed during review of the facilities Life Safety Records the records showed discrepancies and were outdated.

At Approximately 11:10AM - While on tour with the Facility Plant Manager observed in the MARKETING OFFICE above ceiling the rated wall separating the ADULT UNIT and TIME CLOCK HALL, a penetration exposing the structural steel of the building and penetration through the wall.

At Approximately 11:14AM - While on tour with the Facility Plant Manager observed in the TIME CLOCK HALL at the Smoke Barrier Doors above the ceiling to T-HALL several penetrations through the wall not fire stopped.

At Approximately 11:19AM - While on tour with the Facility Plant Manager observed in the MAINTENANCE DIRECTORS OFFICE above ceiling several penetrations through the wall into the ADULT WING not fire stopped.

At Approximately 11:23AM - While on tour with the Facility Plant Manager observed in the TIME CLOCK HALL at the Smoke Barrier Doors to the ADULT WING above ceiling several penetrations through the wall not firestopped.

At Approximately 11:34AM - While on tour with the Facility Plant Manager observed in T-HALL the Smoke barrier wall to CHEMICAL DEPENDENCY had discrepancies on the barrier walls direction after review of the LIFE SAFETY DRAWINGS. The Barrier wall to the ELECTRICAL ROOM had numerous holes through the block.

At Approximately 11:47AM - While on tour with the Facility Plant Manager observed in the RECEIVING HALL near the ELECTRICAL ROOM 2 pipe penetrations through the smoke barrier wall were the original fire stopping was aging and parts of the penetrations were not sealed any longer.

At Approximately 11:48AM - While on tour with the Facility Plant Manager observed in the RECEIVING HALL above the smoke barrier doors to the MAINTENANCE HALL a bundle of low voltage wiring not properly fire stopped.

At Approximately 11:56AM - While on tour with the Facility Plant Manager observed in the ADULT WING after review of the LIFESAFETY DRAWINGS the facility did not have listed on the drawings the SMOKE BARRIER DOORS separating the unit. The doors were physically present and operational. Per NFPA 101 19.3.7.1 separation of a smoke zone shall be provided for sleeping rooms for than 30 patients.

At Approximately 12:06PM - While on tour with the Facility Plant Manager observed in the ADULT WING above 2 hour barrier doors separating the ADOLESCENT WING a penetration above ceiling of 2 cables pulled through the wall not fire stopped.

At Approximately 12:17PM - While on tour with the Facility Plant Manager observed in the SENIOR CARE MANAGERS OFFICE above ceiling near the closet a penetration not fire stopped through the 2 hour barrier wall separating the ADULT WING and the ADOLESCENT WING.

At Approximately 12:45PM - While on tour with the facility plant manager observed above ceiling at the 2 hour barrier wall separating the ADOLESCENT WING and the AUTISM WING a penetration of a flex conduit not fire stopped.

All observations of deficiencies were confirmed by the Facility Plant Manager.

Based upon observation and interview, the facility failed to ensure that doors in smoke barriers are 1 3/4 inch solid bonded wood-core doors or construction that resists fire for 20 minutes, are self-closing or automatic-closing and provide a minimum width of 32 inches as required by 19.3.7.6, 18.3.7.8, and 19.3.7.9. This deficient practice could affect 56 occupants in the event of evacuation of the facility and the reliability of the separation for the duration as designed per the Life safety drawings .

Findings Include:
On 12-11-17 at approximately 11:26AM the following observations were made:

At Approximately 11:26AM - While on tour with the Facility Plant Operations Manager observed the SMOKE BARRIER DOOR separating the TIME CLOCK HALL and the ADULT WING, the glass vision panels in the door were taped over and covered by construction paper. Further investigation into the glass revealed the glass was fogged out halfway up, however staff had covered the glass further to prevent patients sitting and staring out the door.

All Observations were confirmed by the plant Operations Manager.

Based upon observation and interview, the facility failed to ensure that power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99 and 400-8 of NFPA 70, and TIA 12-5 and that extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect 28 occupants in the event of failure of the electrical circuit resulting in the loss of power and possible electrical fire.

Findings Include:
On 12-11-17 at approximately 10:00AM the following observations were made:

At Approximately 10:52AM - While on tour with the Facility Plant Manager observed in the room marked "COO OFFICE", the use of an extension cord as permanent wiring. Also the cord had a ground bypass adapter installed which fed power to a surge protector by-passing any electrical grounding.

All Observations of deficiencies were confirmed by the Facility Plant Manager.