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The facility has failed to ensure that the original fire rated construction of the building has been maintained. Failure to maintain fire separation construction could allow for smoke, heat, and fire to quickly spread through the building, and thus place patients, visitors, and staff at risk of fire.

The findings include, but are not limited to:

During the facility tour on July 28, 2017 between the hours of 1:00pm and 3:00pm, I observed penetrations in fire barriers in the following locations:

1. Patient wing employee restroom was observed to have a penetration in the ceiling created by new light fixture.

Interview with Maintenance Director revealed that maintenance staff was not aware of this breach in fire resistive construction. Maintenance staff advised me that this was corrected on site.

This finding was observed and discussed with the Maintenance Staff.

The facility has failed to ensure that the fire alarm system receive its required testing, servicing, and maintenance. This could allow for the fire alarm system to become inoperable and leave patients, visitors, and staff at risk of no fire alarm protection.

The findings include, but are not limited to:

During document review between the hours of 9am and 12:00pm, I observed that the last annual servicing of the fire alarm system was in October of 2014 by Inland Alarm.

Interview with Maintenance Staff revealed that the fire alarm panel was upgraded in 2015. However, the service contract was not renewed. The facility was placed on fire watch until the system receives annual servicing and annual contract has been established.

This finding was observed and discussed with Maintenance Staff

The facility has failed to ensure that portable fire extinguishers are mounted at the approved height as required by NFPA 10. This could place patients, visitors, and staff at risk of injury and inability to reach the fire extinguishers in a timely manner.

The findings include, but are not limited to:

During the facility tour on July 28, 2017 between the hours of 1:00pm and 3:00pm, I observed that Administration hallway had fire extinguisher over 5 feet height in height.

Interview with Maintenance staff revealed that they were unaware of the height requirement.

This finding was observed and discussed with the Maintenance Staff.

The facility has failed to ensure that the premises is free of electrical hazards and is using power strips and adaptors in an approved manner. Failure to use power strips, extension cords, and electrical adaptors in an approved manner could allow for patients, visitors, and staff at risk of an electrical fire.

The findings include, but are not limited to:

During the facility tour on July 28, 2017 between the hours of 1:00pm and 3:00pm, I observed unapproved use of power strip and extension cord in the following location:

Purchasing was observed to be have a yellow extension cord for a portable heater. The heater was unplugged at time of survey. This office was also observed to have a red 3 pronged extension cord used as a permanent source of power. The office had a power strip plugged into this extension cord.

Interview with Maintenance Director revealed that maintenance staff had observed this activity. These items were removed and corrected on site.

This finding was observed and discussed with the Maintenance Staff.