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Through observation during the survey October 26, 2011, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Director of Plant Operations and CEO, two (2) resident room doors did not latch into their frames to create a smoke sill.

1.) Resident room #106 (Corrected on-site)
2.) Resident room #133 (Corrected on-site)

1.) Through record review, conversation, and observation, during the survey October 26, 2011, it was determined that the facility failed to conduct fire drills at least quarterly on each shift.

During the exit interview with the Director of Plant Operations and CEO, the Director of Plant Operations stated that Vibra Hospital conducts their scheduled fire drills without notifying Haven Behavioral of the time or day when drills will be performed. Being that both of these facilities share one (1) fire alarm system, activation of the fire alarm from Vibra Hospital will activate all components of the fire alarm system in Haven Behavioral.

In addition, the facility has no knowledge of the fire drills to be conducted, all alarms are treated as real fire emergencies and therefore, proper supervision and documentation of the staff is not accomplished.

2.) Through conversation, and observation, during the survey October 26, 2011, it was determined that the facility failed to conduct a fire drill as defined in the facilities Plans and Procedures.

During the walk through of the facility with the Director of Plant Operations, a fire drill was conducted. The nurse call button was activated in room #125 at 2:45 p.m. At one (1) minute and five (5) seconds, a nurse entered room #125 and was instructed that there was currently a fire in the room and one (1) resident was on the bed. The nurse was instructed to follow the facilities Plans and Procedures to address the fire emergency being simulated. The nurse stated that she didn't know what to do and stated that she would go get help. At eight (8) minutes and fifty (50) seconds, the nurse had not returned to the room. At that time the maintenance staff was instructed to go to the nurses' station to inform the staff of a fire in room #125. At eleven (11) minutes, a second (2) nurse entered room #125 and performed the proper steps as described in the facilities Plans and Procedures Manual to mitigate the problem. The fire drill concluded at thirteen (13) minutes.

Through observation, during the survey October 26, 2011, it was determined that the facility failed to maintain the automatic sprinkler system in a reliable operating condition.

During the walk through of the facility with the Director of Plant Operations and CEO, one (1) escutcheon was found to be missing on the fire sprinkler head located in the West Entrance by the cross corridor door.

(Corrected on-site)

Through observation and record review, during the survey October 26, 2011, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During the walk through of the facility with the Director of Plant Operations and CEO, all rooms and offices on the 2nd half of the facility (Northwest half) contained curtains which did not contain tags or markings showing they met NFPA 701 standard. The facility also could not furnish any documentation showing that the curtains in these areas had been treated in accordance with NFPA 701.

Through interviews and observation, during the survey October 26, 2011, it was determined that the facility failed to install generator components per NFPA 110 requirements.

During the walk through of the facility, observation and interviews with the Director of Plant Operations ;

1) The diesel fueled emergency generator, failed to have a remote alarm annunciator in a location readily observed by operating personnel. Per 19.2.9.1, 7.9.2.3 and 2000 Edition of NFPA 110 section 3-5.6.1 "A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel."

2) The generator failed to contain a remote shut off switch as required per NFPA 110, section 3-5.5.6 "All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building."