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Based on observation and staff interview, the facility did not maintain a minimum 2-hour fire resistance rating on interior walls. 19.1.6.4, 19.1.6.5. This deficient practice could affect all patients within the smoke compartment.

Findings Include:

On a facility tour between the hours of 0900 and 1600 on April 05, 2017, observation revealed that there was storage in the Orange Building, lower level, that was constructed of fire rated plywood.


This deficient practice was verified by a Facility Engineer at the time of discovery.

Based on observation and staff interview, the facility did not maintain self-closing doors in exit passageways, stairway enclosures, horizontal exits, smoke barriers, or hazardous areas. 19.2.2.2.7, 19.2.2.2.8. This deficient practice could affect all patients on this floor.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 05, 2017, observation revealed that the door separating the Blue and Green buildings at G-3.005, was utilizing a hold-open device, but did not have smoke detection within 5 feet of the device.


This deficient practice was verified by a Facility Engineer at the time of discovery.

Based on observation and staff interview, the facility did not maintain adequate protection of vertical openings to include stairways, elevator shafts, light and ventilation shafts, and chutes between floors. 19.3.1.1 through 19.3.1.6. This deficient practice could affect all 385 patients.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 04, 2017, observation revealed that in the lab area, Core 12, there was a pipe penetration above the ceiling line through the adjacent shaft that had block broken out and has not maintained the 2 hour rating.


This deficient practice was verified by a Facility Engineer at the time of discovery.

Based on observation and staff interview, the facility did not install and maintain cooking equipment in accordance with NFPA 96 and NFPA 101. 19.3.2.5.2, 19.3.2.5.3, 19.3.2.5.4, 19.3.2.5.1, 19.3.2.5.5. This deficient practice could affect all patients within the smoke compartment.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 04, 2017, observation revealed that the residential cooking range in B-3.125 did not have a remote isolation lockout to disconnect power to the range.


This deficient practice was verified by a Facility Engineer at the time of discovery.

Based on observation and staff interview, the facility failed to install and approved automatic sprinkler system in accordance with the NFPA 13, Standard for Installation of Sprinkler Systems. LSC 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1). This deficient practice could affect an undetermined amount of patients and staff in this room.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 05, 2017, observation revealed that Observation revealed that the facility was using heat collectors above 2 sprinkler heads in G-L.141.


This deficient practice was verified by a Facility Engineer at the time of discovery.

Based on observation and staff interview, the facility failed to install and approved automatic sprinkler system in accordance with the NFPA 13, Standard for Installation of Sprinkler Systems. LSC 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1). This deficient practice could effect any patients or staff in that room.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 04, 2017, observation revealed that P-2.652 was not sprinkler protected or separated by 1-hour fire rated construction.


This deficient practice was verified by a Facility Engineer at the time of discovery.

Based on observation and staff interview, the facility did not ensure that all corridor maintained a positive latch while in the closed position. 7.2.1.9, 8.3, 19.3.6.3, 19.3.6.3.6. This deficient practice could affect all patients on that floor.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 05, 2017, observation revealed that the pass through cabinet doors in the Orange Building, 5th floor, patient sleeping rooms, did not positively latch in the closed position.


This deficient practice was verified by a Facility Engineer at the time of discovery.

Based on documentation review and staff interview, the facility could not provide documentation that a transmission of the fire alarm signal was sent as required by 2012 NFPA 101, Section 19.7.1.4. through 19.7.1.7. This deficient practice could affect all 385 patients.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 04, 2017, documentation review revealed that the facility could not provide evidence for documenting the transmission of a fire alarm signal during monthly fire drills.


This deficient practice was verified by a Facility Engineer at the time of discovery.

Based on documentation review and staff interview, the facility could not provide documentation that a transmission of the fire alarm signal was sent as required by 2012 NFPA 101, Section 19.7.1.4. through 19.7.1.7. This deficient practice could affect all 385 patients.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 05, 2017, documentation review revealed that the facility could not provide evidence for documenting the transmission of a fire alarm signal during monthly fire drills.


This deficient practice was verified by a Facility Engineer at the time of discovery.

Based on document review and staff interview, the facility did not maintain the emergency back-up generator in accordance with the 2012 NFPA 99. 6.4.4, 6.5.4, 6.6.4. These deficient practices could effect all 385 patients.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 04, 2017, documentation review revealed that the facility could not provide evidence for conducting the emergency back-up generator weekly visual inspections. Inspections are currently being done on a monthly basis.


These deficient practices were verified by a Facility Engineer at the time of discovery.

Based on document review and staff interview, the facility did not maintain the emergency back-up generator in accordance with the 2012 NFPA 99. 6.4.4, 6.5.4, 6.6.4. These deficient practices could effect all 385 patients.

Findings include:

On a facility tour between the hours of 0900 and 1600 on April 05, 2017, documentation review revealed that the facility could not provide evidence for conducting the emergency back-up generator weekly visual inspections. Inspections are currently being done on a monthly basis.


These deficient practices were verified by a Facility Engineer at the time of discovery.