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Based on observation and interview the facility staff failed to ensure that self-closing doors were not obstructed from self-closing.

The deficiencies had the potential to delay the closure of the doors and allow the passage of smoke, heat and fire during a fire emergency.

Findings:

On 4/10/18 between 8 a.m. and 4 p.m. the following were observed:

Building B Southwest

1. The self-closing corridor door at the nurses office was held fully opened by the use of a kick door holder engaged at the front of the door.

During an interview at the same time as the observation the Plant Operations Manager stated he did not know how long the kick door holder had been there.


On 4/11/18 between 8 a.m. and 4 p.m. the following was observed:

Building A East

2. The day room self-closing corridor door was held fully opened by a stack of five chairs that was placed in front of the door. At the time of the observation the Plant Operations Manager removed the stacked chairs to allow the door to close. At this time, unit staff again placed the stacked chairs in front of the corridor door to hold the self-closing corridor door open.

During an interview at the same time as the observation RN B stated that the door needed to remain open if there was a patient in the day room and that staff had been told that the door needed to be kept open (by unidentified person), and that she didn't know if there was a facility policy indicating that the door needed to be maintained open.

Building C South

3. The day room self-closing corridor door was held fully opened by a 3 ft x 3 ft food wooden table that was placed in front of the door. Closer observation revealed that there was a patient in the day room.

During an interview at the same time as the observation, RN C stated that there was no reason for the door to be held open, and that when there is a patient in the room, there has to be a staff in the room with the patient. RN C stated, that the door was held open because the housekeeper was in the room.

4. The evaluator noted that the day room self-closing corridor door was held fully opened by a chart rack placed in front of the door that opened to the nurses station and exit corridor.

Building C North

5. The day room self-closing corridor door was held fully opened by a wood chair.

NFPA 101 Life Safety Code 2012 Edition

7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Based on observation and interview the facility staff failed to ensure that an exit was marked by an approved sign.

The deficiency had the potential to delay or prevent the rapid egress in the event of an evacuation.

Finding:

Building G (Kitchen)

On 4/11/18 at 11 a.m. the evaluator noted that there was no exit sign at the kitchen exit door that exited directly to the outside.

During an interview at the same time as the observation, the Plant Operations Manager identified the exit as part of an evacuation route.

Review of the evacuation floor plan for the kitchen identified the door as part of the evacuation route.

NFPA 101 Life Safety Code 2012 Edition

8.3.5.6.1 Membrane penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a membrane of a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a fire-stop system or device and shall comply with 8.3.5.1 through 8.3.5.5.2.


This Code was not met as evidenced by:

Based on observation and interview the facility staff failed to ensure there were no penetrations in the ceilings and wall.

The deficiencies had the potential to facilitate the passage of smoke, heat and fire during a fire emergency.

Findings:

Building B Common Area

1. On 4/10/18 at 11:15 a.m., the evaluator noted that there was a 1 ½ inch by 1 inch penetration at the ceiling next to the fire sprinkler cover in the seclusion room bathroom.

Building I (Intake)

2. On 4/11/18 at 11:20 a.m., the evaluator noted that there was a one inch diameter penetration through the ceiling of the medical records room.

During an interview at the same time as the observation the Plant Operations Manager stated that penetration was from a data project that they forgot to seal.

3. The evaluator observed a two foot by one foot section of missing wall inside a closet that housed a natural gas tank that fueled a fifty gallon capacity water heater.

During an interview at the same time as the observation the Plant Operations Manager stated that the wall needed to be replaced and that he did not know why the wall was opened.

1. NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition

13.3.1* Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

This Standard was not met as evidenced by:

Based on observation and interview the facility staff failed to ensure a control valve sign was present.

The deficiency had the potential to create a delay and / or provide visual identification of device operational function during inspection assessment by the authority having jurisdiction.

Finding:

Building A West

On 4/10/18 at 2:50 p.m. the evaluator noted that there was an identification signage missing at the fire sprinkler's inspector test valve access door located at a patio wall.

During an interview at the same time as the observation the Plant Operations Manager confirmed that the access door led to the location of the inspector's test valve.
The evaluator also noted a missing cap at the concealed fire sprinkler head located at the ceiling in the clothing storage room of the environmental services area on 4/11/18 at 8:30 a.m. in Building A East

During an interview at the same time as the observation, the Plant Operations Manager acknowledged there was a missing cap at the concealed fire sprinkler head.

Based on observation and interview the facility staff failed to ensure that corridor doors were able to be held closed position.

The deficiency had a potential to created a condition conducive to the potential transfer of smoke, heat, gases, and fire during a fire emergency.

Findings:

Building A North

1. On 4/10/18 at 3:10 p.m., the corridor door at patient room 236 could not be held in the closed position.

During an interview at the same time as the observation the Plant Operations Manager stated that the door could not be held in the closed position because the door latch shifted due to the slamming of the doors.

Building B South

2. At 12:10 p.m., the corridor door at patient room 168 could not be held in the closed position .

During an interview at the same time as the observation the Plant Operations Manager stated that the door could not be held in the closed position because the striker was not engaged


Building C South

3. On 4/11/18 at 3:10 p.m., the staff room corridor door was held fully opened by a chair that was placed in front of the door. The room was unoccupied at the time of the observation.

Building I (Intake)

4. At 11:20 a.m., the corridor door of consult door 2 could not be held in the closed position .

Building A North

Based on observation and interview the evaluator noted that there were penetrations at a smoke barrier wall.

The deficiency had the potential to facilitate the passage of smoke, heat and fire during a fire emergency.

Finding:

On 4/10/18 at 3:20 p.m., the evaluator noted that there were two ¾-inch penetrations through one side of a smoke barrier wall located above the drop down ceiling of the cross corridor door by the laundry room.

During an interview at the same time as the observation the Plant Operations Manager acknowledged the penetrations.

NFPA 70 National Electrical Code 2011 Edition

110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a workmanlike manner.

406.5 Receptacle Mounting. Receptacles shall be mounted in boxes or assemblies designed for the purpose, and such boxes or assemblies shall be securely fastened in place unless otherwise permitted elsewhere in Code.

This Code was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that electrical wiring and equipment were in accordance with NFPA 70 due to the facility's missing electrical cover plates and loose electrical receptacles.

The deficiencies had the potential create a risk of electrical shock and fire.

Building B Southwest

1. On 4/10/18 at 11:55 a.m., the evaluator observed an electrical junction box that was missing a cover plate that exposed electrical wiring. The box was located above the drop down ceiling at the cross corridor door by consult room 2.

During an interview at the same time as the observation the Plant Operations Manager stated that he didn't know what or if the electrical wiring was serving any purpose.

Building F (Gym)

2. On 4/11/18 at 10:25 a.m., the evaluator observed that there was a loose electrical receptacle by the stage in the gym.

3. The evaluator also noted that there was a missing electrical cover plate at an electrical box that exposed orange and white electrical wires at the wall by the basketball hoop in the gym.

During an interview at the time of the observation and after testing the wires, the Plant Operations Manager stated that the electrical wires were live wires and had power.

4. The evaluator noted a loose electrical receptacle and electrical box at the wall by the door with "No Exit" sign in the gym.

During an interview at the same time of the observations the Plant Operations Manager stated that the gym (building F) is being used by both inpatients and outpatients.

Building I (Intake)

5. The evaluator noted a broken electrical receptacle at the corridor by consult room

NFPA 101 Life Safety Code 2012 edition

5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.


19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected.

19.4.10 All documentation shall be maintained and made available for review by the AHJ.

This Code and Standards was not met as evidence by:

Based on document review and interview the facility staff failed to provide documented evidence that of the damper testing and inspection, results, and corrections if applicable.

The deficiency had the potential to not restrict the passage of smoke during a fire emergency.

Finding:

During a document review, on 4/12/18 between 8 a.m. and 4 p.m., the facility failed to produce any evidence documented evidence of testing and inspection of the dampers.

During an interview at the same time as the document review, the Plant Operations Manager stated that he was under the belief that the testing and inspection of the dampers were not required and presented the evaluator with an e-mail.

Review of the e-mail indicated that the Healthcare Interpretations Task Force (HITF) published an interpretation (November 2000) of NFPA 101, section 1-3.13.2 1997 edition which indicated, that non required smoke, fire and combination smoke/fire dampers, that are not obvious to the to the public do not have to be maintained or removed.

The email further indicated that it was however important, that the organization ensures that the dampers had not failed and were restricting air flow to the areas served, and that how an organization elects to accomplish verification is up to them.

By the end of the survey, the facility had failed to provide with any documented evidence of damper testing and inspection, results, and/ or corrections. The facility also did not provide any documented verification that the dampers have not failed in restricting air flow.

At 4:30 p.m., during an interview, the Plant Operations Manager was provided the opportunity to fax the documented evidence of damper testing and inspection, results, and corrections if applicable to the evaluator by 4/13/18. On 4/13/18 the evaluator again received a copy of the same e-mail that was previously presented to the evaluator during the survey.

The evaluator did not receive any documented evidence of damper testing and inspection, results and corrections as of 4/30/18.

NFPA 101 Life Safety Code 2012 edition

19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

This Code was not met as evidenced by:

The facility staff failed to adopt smoking regulation that included the provision of Metal containers with self-closing cover devices into which ashtrays can be emptied and readily available to all areas where smoking was permitted.

The effective adoption and implementation of smoking regulations, policies, and procedures is an essential component in the prevention of fires that are caused by smoking.

Findings:

Building A West

On 4/10/18 at 2:50 p.m., the evaluator observed that there was a large accumulation of cigarette butts on the patio lawn.

On 4/12/18 at 10:20 a.m., the housekeeping supervisor stated that there was no procedure of how to remove the cigarette butts from the enclosed patios where smoking was permitted, and that there is no schedule of how often the cigarette butts should be cleaned from enclosed patios, although the patio was to be cleaned at least once daily.

At 10:35 during an interview the housekeeper stated that daily she sweeps up the cigarette butts from the enclosed patio and places the cigarette butts in a plastic trash bag that contains trash including paper products. She further stated that she then ties and place the bag on an open utility cart which she rolls in to the housekeeping closet.

On 4/12/18 during document review between 8 a.m. and 4 p.m. the evaluator noted that there there was no documented evidence that regulations were adopted for metal containers with self-closing devices into which ashtrays could be emptied and readily available to all areas where smoking was permitted.