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Based on observation and interview, the facility failed to ensure the means of egress through the double door set in the crisis stabilization unit was readily accessible for clients without a clinical diagnosis requiring specialized security measures. Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side unless otherwise permitted by LSC 19.2.2.2.4. Door-locking arrangements shall be permitted in accordance with 19.2.2.2.5.2. This deficient practice could affect over 15, staff and visitors if needing to exit the facility.

Findings include:

Based on observations and interviews during a tour of the facility with the Safety and Security Coordinator (SSC) and Director of Quality Improvement (DOQ) on 05/19/25 at 3:30 p.m. the double doors separating the Full Crisis Unit from the Mobil Crisis Unit, marked from each side as a facility exit, was magnetically locked and could be opened with panic hardware from the Mobil Crisis side. However, the doors could only be opened from the Full Crisis side without the use of a badge or special key. The aforementioned doors were not connected to the hospital's fire alarm system and this part of the facility did not have a fire alarm system. The DOQ stated the arrangement with the doors was added during a recent remodel/refresh of this part of the facility.

This finding was acknowledged by the SSC and DOQ at the time of observation and again at the exit conference with the SSC and DOQ each present.

Based on observation and interview, the facility failed to ensure 1 of over 3 hazardous area doors, such as storage rooms, were provided with properly working self-closing devices. This deficient practice could affect more than 5 residents, as well as staff and visitors in the near the nurse's office area.

Findings include:

Based on the facility tour and interview with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/19/25 at 3:45 p.m., an office/room the facility was using as the nurse's station was greater than 50 square feet and contained a number of combustible items, such as, paper, and over 8 large cardboard boxes. The corridor door to this office/room/nurse's station was not equipped with a self-closing device and did not self-close and latch into the door frame.

This finding was acknowledged by the SSC and FMM at the time of observation and again at the exit conference with the SSC and Director of Quality present.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all building occupants.

Findings include:

Based on records review and interview with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/19/25 at 1:30 p.m. no documentation could be provided regarding a visual semi-annual fire alarm system inspection. The FMM stated that the facility was not aware of the 6-month visual inspection requirement. This facility is located in a portion of the campus where the fire alarm system is maintained by the facility.

This finding was acknowledged by the SSC and FMM at the time of observation and again at the exit conference with the SSC and Director of Quality present.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all building occupants.

Findings include:

Based on records review and interview with the Safety and Security Coordinator (SSC) and Hospitals Facilities Maintenance Manager on 05/19/25 at 1:30 p.m. no documentation could be provided regarding a visual semi-annual fire alarm system inspection. The Hospitals Maintenance Manager stated that the facility was not aware of the 6-month visual inspection requirement. The In-Patient Center is located in a portion of the building where the fire alarm system is maintained by the hospital. The hospital staff stated that they would need to get a points list developed and a semiannual inspection scheduled in their Computer Maintenance Monitoring System.

This finding was acknowledged by the SSC at the time of observation and again at the exit conference with the SSC and Director of Quality present.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all building occupants.

Findings include:

Based on records review and interview with the Safety and Security Coordinator (SSC) and Hospitals Facilities Maintenance Manager on 05/19/25 at 1:30 p.m. no documentation could be provided regarding a visual semi-annual fire alarm system inspection. The Hospitals Maintenance Manager stated that the facility was not aware of the 6-month visual inspection requirement. The UNITY HOUSE is located in a portion of the building where the fire alarm system is maintained by the hospital. The hospital staff stated that they would need to get a points list developed and a semiannual inspection scheduled in their Computer Maintenance Monitoring System.

This finding was acknowledged by the SSC at the time of observation and again at the exit conference with the SSC and Director of Quality present.

1. Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 3 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all residents, staff, and visitors in the facility.

Findings include:

Based on review of the quarterly sprinkler system inspection records with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/19/25 at 3:15 p.m., only 1 (dated 06/13/24) of the required 4 quarterly sprinkler inspections was available for review. During an interview at the time of record review, the FMM acknowledged there was no written documentation available to show the sprinkler system had been inspected three of the four quarters stating that they had only had one inspection per year since he began working at the facility a few years ago. During a tour of the Riser Room on 05/20/25 at 10:05 a.m., hang tags from the sprinkler company indicated that only the aforementioned inspection was conducted. Previous hangtags from several years earlier revealed that once upon a time four quarterly inspections were conducted on the sprinkler system. The FMM stated he would contact the facility's sprinkler provider and begin 4 quarterly inspections immediately.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet and a sprinkler wrench on the premises. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. This deficient practice could affect all residents and staff in the facility.

Findings include:

Based on the facility tour and interview with the Safety and Security Coordinator (SSC) and Facilities Maintenance Manager (FMM) on 05/20/25 at 10:10 a.m., there was one spare sprinkler cabinet in the riser room that included in excess of 15 spare sprinklers; 7 or more of which were not in their own protected slot. They were stored loose in and on the cabinet and not secured in holders. Based on interview at the time of the observation, the FMM agreed the spare sprinkler cabinet had spare sprinklers not in protected slots.

This finding was acknowledged by the SSC and FMM at the time of observation and again at the exit conference with the SSC and Director of Quality present.