HospitalInspections.org

Based on observation and interview, the facility failed to ensure each fire barrier maintained a 2-hour fire resistance rating. This has the potential to affect all patients, family, and staff in the building. The census at the time of the survey was 69 patients.

Findings include:

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. A tour of the southern half of the building revealed a small north/south corridor that bisected two classroom areas. The corridor lead to a 2 hour fire wall that separated the building from an addition that held office spaces. Observation of the wall revealed a door propped open with a pallet of paper.

On 12/06/12 at 4:15 P.M. during an interview, Staff CC confirmed the observation. Staff CC stated the staff propped the door open because their keys to it didn't always work properly.

Tour of the geri-psychiatric care unit was conducted on 12/04/12 at 2:25 P.M. A 2 hour fire barrier, between the patient sleeping area and a non-sleeping area used as a multipurpose room for patients, was observed during the tour. Observation of the barrier above the drop-down ceiling revealed two one-to-two inch conduits used for cables lacked a fire barrier above the ceiling.

Based on observation and interview, the facility failed to ensure each fire barrier maintained a 2-hour fire resistance rating. This has the potential to affect all patients, family, and staff in the building. The census at the time of the survey was 69 patients.

Findings include:

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. A tour of the southern half of the building revealed a small north/south corridor that bisected two classroom areas. The corridor lead to a 2 hour fire wall that separated the building from an addition that held office spaces. Observation of the wall revealed a door propped open with a pallet of paper.

On 12/06/12 at 4:15 P.M. in an interview Staff CC confirmed the observation. He/she stated the staff was propping the door open because their keys to it didn ' t always work properly.

Tour of the geripsychiatric care unit was conducted on 12/04/12 at 2:25 P.M. The tour revealed a 2 hour fire barrier between the patient sleeping area and a non-sleeping area used as a multipurpose room for patients. Observation of the barrier above the drop-down ceiling revealed two one-to-two inch conduits used for cables and were not fire stopped within.

Based on observation, interview, and review of building permit sets, the facility failed to maintain a permissible building construction type. This has the potential to affect all patients in the facility. The census at the time of the survey was 69 patients.

Findings:

Review of building permit set - Volume 1 was completed on 12/06/12. The review revealed the permits were dated 05/27/05 and indicated major renovations would occur, including but not limited to, an up grading of a main corridor to a one hour fire tunnel, the removal of a wooden stairwell, the removal of the existing ceilings, and the installation of a one hour occupancy separation. The square footage of the major renovations was over 10,000 square feet. The permit set indicated the building was of Type III(2,0,0), i.e., unprotected construction.

On 10/05/12 at 9:15 A.M., using a ladder to gain access, a tour was conducted on top of the roof of the structure with Staff CC. The surveyor was unable to determine the construction type of the roof.

On 10/05/12 at 2:20 P.M. during an interview, Staff DD confirmed he/she had spoken with the building's architect who confirmed the building's roof was unrated.

Based on observation and interview, the facility failed to ensure the each space that opened onto a corridor was protected by either an electrically supervised automatic smoke detection system or have direct supervision by facility staff. This affected the multipurpose room in the psychiatric intensive care unit, and had the potential to affect all patients, staff, and visitors. The census at the time of the survey was 69 patients.

Findings include:

A tour of the psychiatric intensive care unit was conducted on 12/03/12 at 1:45 P.M. with Staff CC. The tour revealed a 920 square foot multi-purpose room in the southwest corner of the building. The room was observed to open onto the corridor. During the tour the room was observed to have patients watching television and socializing among each other. The room was observed not to have smoke detectors and was not being supervised by staff at the moment.

During the tour, the observation was confirmed by Staff CC.

A second tour of the psychiatric intensive care unit was conducted on 12/04/12 at 9:40 A.M. with Staff CC and DD. Staff was in attendance at the threshold of the door, but unable to visualize the activity of the whole room.

During the tour, Staff DD confirmed the finding, and explained staff are to monitor the patients every 15 minutes.

Based on observation, and interview, the facility failed to ensure the each space that opened onto a corridor was protected by either an electrically supervised automatic smoke detection system or had direct supervision by facility staff. This affected the multipurpose room in the psychiatric intensive care unit, and had the potential to affect all patients, staff, and visitors. The census at the time of the survey was 69 patients.

Findings include:
A tour of the psychiatric intensive care unit was conducted on 12/03/12 at 1:45 P.M. with Staff CC. The tour revealed a 920 square foot multi-purpose room in the southwest corner of the building. The room was observed to open onto a corridor. During the tour the room was observed to have patients watching television and socializing among each other. The room was observed to lack smoke detectors and was not being supervised by staff at the moment of the observation.

During the tour, the observation was confirmed by Staff CC.

A second tour of the psychiatric intensive care unit was conducted on 12/04/12 at 9:40 A.M. with Staff CC and DD. Staff was in attendance at the threshold of the door, of the multipurpose room but were unable to visualize the activity of the whole room.

During the tour, Staff DD confirmed the finding, and explained the hospital's expectation is staff are to monitor the patients every 15 minutes.

Based on observation and interview, the facility failed to ensure each door(s) protecting corridor openings resisted the passage of smoke. This affected the double doors in the lobby/kitchen area, and the doors in the outpatient area, and has the potential to affect all patients, staff, and visitors in the building. The census at the time of the survey was 69 patients.

Findings include:

A tour of the lobby area was included in the tour of the kitchen/dining area on 12/04/12 at 10:30 A.M. that was conducted with Staff CC. The tour revealed a set of double doors in the wall that separated the lobby from the main corridor. These doors were observed to have a gap mostly closed off with a rubber strip. The rubber strip had multiple gaps in it with the largest being two inches in length. Two other gaps were one inch in diameter.

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. (The outpatient area was within the building and used adjacent to a patient sleeping area.) During the tour, the area was observed to have an east/west corridor. At the east end of the corridor a door leading to the dayroom was observed to have half-inch holes in it. Another door leading to office space " A " was found to have a half-inch hole in it.

During the tour Staff CC confirmed the findings stating that after self closers had been removed from the doors, the holes that were left behind did not get filled.

Based on observation, and interview, the facility failed to ensure each door(s) protecting corridor openings resisted the passage of smoke. This affected the double doors in the lobby/kitchen area, and the doors in the outpatient area. This deficiency has the potential to affect all patients, staff, and visitors in the building. The census at the time of the survey was 69 patients.

Findings include:

A tour of the lobby area was included in the tour of the kitchen/dining area on 12/04/12 at 10:30 A.M., and was conducted with Staff CC. The tour revealed a set of double doors in the wall that separated the lobby from the main corridor. These doors were observed to have a gap mostly closed off by a rubber strip. The rubber strip had multiple gaps in it with the largest being two inches in length. Two other gaps were one inch in diameter.

A tour of the outpatient area was included with the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. (The outpatient area was within the building and used adjacent to a patient sleeping area.) During the tour, the area was observed to have an east/west corridor. At the east end of the corridor a door leading to the dayroom was observed to have half-inch holes in it. Another door, leading to office space " A " was observed to have a half-inch hole in it.

During the tour Staff CC confirmed the findings stating that after self closers had been removed from the doors, the holes that were left behind did not get filled.

Based on interview and record review, the facility failed to hold fire drills under varying conditions at unexpected times. This has the potential to affect all patients and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

Review of the facility ' s fire drills since 01/01/12 revealed they were conducted quarterly on each shift. The review revealed the second drill in each quarter was held between 3:00 P.M. and 3:30 P.M. The review revealed the third drill in each quarter was held between 6:55 A.M. and 7:02 A.M.

Review of the safety committee meeting minutes was completed on 12/06/12. The review revealed in January 2012 meeting a 2012 fire drill calendar. This calendar indicated the second drill in each quarter was to be held at 3:30 P.M., and the third drill in each quarter to be held at 7:00 A.M. The calendar does not speak to holding drills under varying conditions and unexpected times.

Based on interview, and record review, the facility failed to hold fire drills under varying conditions at unexpected times. This has the potential to affect all patients and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

Review of the facility's fire drill reports from 01/01/12 revealed they were conducted quarterly on each shift. The review revealed the second drill in each quarter was held between 3:00 P.M. and 3:30 P.M. The review revealed the third drill in each quarter was held between 6:55 A.M. and 7:02 A.M.

Review of the safety committee meeting minutes was completed on 12/06/12. The January Safety Committee minutes revealed a 2012 fire drill calendar. This calendar revealed the second drill in each quarter was to be held at 3:30 P.M., and the third drill in each quarter to be held at 7:00 A.M. The calendar did not speak to holding drills under varying conditions and unexpected times.

Based on observation and interview, the facility failed to continuously maintain its automatic sprinkler system in a reliable operating condition in accordance with the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18 New Health Care, and NFPA 13. This has the potential to affect all patients, staff and visitors in the facility. The census at the time of the survey was 69 patients.

Findings include:

A tour of the kitchen/dining area was conducted on 12/04/12 at 10:30 A.M. with Staff CC. Observation of the sprinkler heads in the dining area revealed six had a screw missing from the escutcheon such that the sprinkler head was not flush with the ceiling, two sprinkler headsmissing the escutcheon altogether, and three coated with dust and dirt.

During the tour, Staff CC confirmed the findings.

A tour of the lobby area was included in the tour of the kitchen/dining area on 12/04/12 at 10:30 A.M. that was conducted with Staff CC. Observation of this area revealed a mini-corridor that bisected an exam room and office spaces. Observation of one office space across from the exam room (indicated as room 181 on the schematic) revealed the office to have a sprinkler. Observation revealed books stacked within the 18 inch zone from the ceiling.

During the tour, Staff CC confirmed the finding.

Based on observation and interview, the facility failed to continuously maintain its automatic sprinkler system in a reliable operating condition in accordance with the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18 New Health Care, and NFPA 13. This has the potential to affect all patients, staff and visitors in the facility. The census at the time of the survey was 69 patients.

Findings include:

A tour of the kitchen/dining area was conducted on 12/04/12 at 10:30 A.M. with Staff CC. Observation of the sprinkler heads in the dining area revealed six that had had a screw missing from the escutcheon such that the sprinkler head was not flush with the ceiling, two missing the escutcheon altogether, and three coated with dust and dirt.

During the tour, Staff CC confirmed the findings.

A tour of the lobby area was included in the tour of the kitchen/dining area on 12/04/12 at 10:30 A.M. that was conducted with Staff CC. Observation of this area revealed a mini-corridor that bisected an exam room and office spaces. Observation of one office space across from the exam room (indicated as room 181 on the schematic) revealed the office to have a sprinkler. Observation revealed books stacked within the 18 inch zone from the ceiling.

During the tour, Staff CC confirmed the finding.

Based on interview and observation, the facility failed to ensure each fire extinguisher was readily accessible in accordance with NFPA 10. This has the potential to affect all patients, family and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

On 12/03/12 at 1:45 P.M. a tour of the psychiatric intensive care unit revealed fire extinguishers to be locked in cabinets within the walls of the facility. During the tour in an interview, Staff CC stated all the extinguishers in the facility were so secured.

On 12/03/12 at 2:20 P.M., during an interview Staff EE had difficulty finding the key for the fire extinguisher in the cabinet. (The surveyor observed the key to be very similar in size and shape to several other keys on the clinician ' s key ring.) Upon placing the key into the lock, Staff EE had difficulty opening the cabinet itself. Unlocking the cabinet required two steps: first, unlocking the lock with one hand, then flipping a latch with the other.

During the tour Staff CC confirmed the fire extinguisher key was similar to other keys on the key ring.

During the tour Staff FF also required assistance to locate the right key to the fire extinguisher cabinet.

Review of the facility ' s safety committee meeting minutes for 2012 was completed on 12/06/12. The review revealed during the 07/12/12 meeting 20 percent of sampled staff were unable to demonstrate how to remove the fire extinguishers from their cases.

Based on interview and observation, the facility failed to ensure each fire extinguisher was readily accessible in accordance with NFPA 10. This has the potential to affect all patients, family and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

On 12/03/12 at 1:45 P.M. a tour of the psychiatric intensive care unit revealed fire extinguishers to be locked in cabinets within the walls of the facility. Staff CC, when interviewed during the tour, stated all the extinguishers in the facility were so secured.

On 12/03/12 at 2:20 P.M., during an interview Staff EE had difficulty finding the key for the fire extinguisher in the cabinet. (The surveyor observed the key to be very similar in size and shape to several other keys on the clinician ' s key ring.) Upon placing the key into the lock, Staff EE had difficulty opening the cabinet itself. Unlocking the cabinet required two steps: first, unlocking the lock with one hand, then flipping a latch with the other.

During the tour Staff CC confirmed the fire extinguisher key was similar to other keys on the key ring.

During the tour Staff FF also required assistance to locate the right key to the fire extinguisher cabinet.

Review of the facility ' s safety committee meeting minutes for 2012 was completed on 12/06/12. The review revealed during the 07/12/12 meeting 20 percent of sampled staff were unable to demonstrate how to remove the fire extinguishers from their cases.

Based on observation and interview, the facility failed to ensure to ensure the building was free of portable space heating devices. This had the potential to affect all patients, visitors and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. (The outpatient area was within the building and used adjacent to a patient sleeping area.) Observation of space " A " revealed a space heater within.

During the tour, Staff CC confirmed the finding.

On 12/04/12 at 11:20 A.M. a tour was conducted of the crisis intervention unit with Staff CC and DD. During the tour an office was observed at the end of the north/south corridor, and perpendicular to the exit at the end of said corridor (designated p109 on the schematic). The office was observed to contain a space heater.

During the tour Staff CC confirmed the finding.

Based on observation and interview, the facility failed to ensure to ensure the building was free of portable space heating devices. This had the potential to affect all patients, visitors and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. (The outpatient area, which is used, was located within the building and adjacent to a patient sleeping area.) Observation of space " A " revealed a space heater within.

During the tour, Staff CC confirmed the finding.

On 12/04/12 at 11:20 A.M. a tour was conducted of the crisis intervention unit with Staff CC and DD. During the tour an office was observed at the end of the north/south corridor, and perpendicular to the exit at the end of said corridor (designated p109 on the schematic). The office was observed to contain a space heater.

During the tour Staff CC confirmed the finding.

Based on observation and interview, the facility failed to ensure weekly generator inspections were documented. This has the potential to affect all patients, staff and visitors who use the facility. The census at the time of the survey was 69 patients.

Findings include:

A review of the facility ' s generator log for 2012 was completed on 12/06/12. The review did not reveal any documentation of a weekly visual inspection for items such as fuel level, coolant level, and condition of the battery.

On the morning of 12/06/12, Staff CC confirmed a log of a weekly visual generator checks were not done.

Based on observation and interview, the facility failed to ensure weekly generator inspections were documented. This has the potential to affect all patients, staff and visitors who use the facility. The census at the time of the survey was 69 patients.

Findings include:

A review of the facility's generator log for 2012 was completed on 12/06/12. The review did not reveal any documentation of a weekly visual inspection for items such as fuel level, coolant level, and condition of the battery.

On the morning of 12/06/12, Staff CC confirmed a log of a weekly visual generator checks were not done.

Based on observation and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular. This has the potential to affect all patients, staff, and visitors in the facility. The census at the time of the survey was 69 patients.

Findings:

On 12/03/12 at 1:45 P.M. a tour of the psychiatric intensive care unit revealed a charting room. Observation within the charting room revealed a 9 receptacle expansion pod with a 6 receptacle power strip plugged into it. Into the power strip there were three receptacles in use.

During the tour, Staff CC confirmed the observation.

Based on observation and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular. This has the potential to affect all patients, staff, and visitors in the facility. The census at the time of the survey was 69 patients.

Findings:

On 12/03/12 at 1:45 P.M. a tour of the psychiatric intensive care unit revealed a charting room. Observation within the charting room revealed a 9 receptacle expansion pod with a 6 receptacle power strip plugged into it. There were three receptacles in use in the power strip.

During the tour, Staff CC confirmed the observation.

Based on observation and interview, the facility failed to ensure each fire barrier maintained a 2-hour fire resistance rating. This has the potential to affect all patients, family, and staff in the building. The census at the time of the survey was 69 patients.

Findings include:

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. A tour of the southern half of the building revealed a small north/south corridor that bisected two classroom areas. The corridor lead to a 2 hour fire wall that separated the building from an addition that held office spaces. Observation of the wall revealed a door propped open with a pallet of paper.

On 12/06/12 at 4:15 P.M. during an interview, Staff CC confirmed the observation. Staff CC stated the staff propped the door open because their keys to it didn't always work properly.

Tour of the geri-psychiatric care unit was conducted on 12/04/12 at 2:25 P.M. A 2 hour fire barrier, between the patient sleeping area and a non-sleeping area used as a multipurpose room for patients, was observed during the tour. Observation of the barrier above the drop-down ceiling revealed two one-to-two inch conduits used for cables lacked a fire barrier above the ceiling.

Based on observation and interview, the facility failed to ensure each fire barrier maintained a 2-hour fire resistance rating. This has the potential to affect all patients, family, and staff in the building. The census at the time of the survey was 69 patients.

Findings include:

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. A tour of the southern half of the building revealed a small north/south corridor that bisected two classroom areas. The corridor lead to a 2 hour fire wall that separated the building from an addition that held office spaces. Observation of the wall revealed a door propped open with a pallet of paper.

On 12/06/12 at 4:15 P.M. in an interview Staff CC confirmed the observation. He/she stated the staff was propping the door open because their keys to it didn ' t always work properly.

Tour of the geripsychiatric care unit was conducted on 12/04/12 at 2:25 P.M. The tour revealed a 2 hour fire barrier between the patient sleeping area and a non-sleeping area used as a multipurpose room for patients. Observation of the barrier above the drop-down ceiling revealed two one-to-two inch conduits used for cables and were not fire stopped within.

Based on observation, interview, and review of building permit sets, the facility failed to maintain a permissible building construction type. This has the potential to affect all patients in the facility. The census at the time of the survey was 69 patients.

Findings:

Review of building permit set - Volume 1 was completed on 12/06/12. The review revealed the permits were dated 05/27/05 and indicated major renovations would occur, including but not limited to, an up grading of a main corridor to a one hour fire tunnel, the removal of a wooden stairwell, the removal of the existing ceilings, and the installation of a one hour occupancy separation. The square footage of the major renovations was over 10,000 square feet. The permit set indicated the building was of Type III(2,0,0), i.e., unprotected construction.

On 10/05/12 at 9:15 A.M., using a ladder to gain access, a tour was conducted on top of the roof of the structure with Staff CC. The surveyor was unable to determine the construction type of the roof.

On 10/05/12 at 2:20 P.M. during an interview, Staff DD confirmed he/she had spoken with the building's architect who confirmed the building's roof was unrated.

Based on observation and interview, the facility failed to ensure the each space that opened onto a corridor was protected by either an electrically supervised automatic smoke detection system or have direct supervision by facility staff. This affected the multipurpose room in the psychiatric intensive care unit, and had the potential to affect all patients, staff, and visitors. The census at the time of the survey was 69 patients.

Findings include:

A tour of the psychiatric intensive care unit was conducted on 12/03/12 at 1:45 P.M. with Staff CC. The tour revealed a 920 square foot multi-purpose room in the southwest corner of the building. The room was observed to open onto the corridor. During the tour the room was observed to have patients watching television and socializing among each other. The room was observed not to have smoke detectors and was not being supervised by staff at the moment.

During the tour, the observation was confirmed by Staff CC.

A second tour of the psychiatric intensive care unit was conducted on 12/04/12 at 9:40 A.M. with Staff CC and DD. Staff was in attendance at the threshold of the door, but unable to visualize the activity of the whole room.

During the tour, Staff DD confirmed the finding, and explained staff are to monitor the patients every 15 minutes.

Based on observation, and interview, the facility failed to ensure the each space that opened onto a corridor was protected by either an electrically supervised automatic smoke detection system or had direct supervision by facility staff. This affected the multipurpose room in the psychiatric intensive care unit, and had the potential to affect all patients, staff, and visitors. The census at the time of the survey was 69 patients.

Findings include:
A tour of the psychiatric intensive care unit was conducted on 12/03/12 at 1:45 P.M. with Staff CC. The tour revealed a 920 square foot multi-purpose room in the southwest corner of the building. The room was observed to open onto a corridor. During the tour the room was observed to have patients watching television and socializing among each other. The room was observed to lack smoke detectors and was not being supervised by staff at the moment of the observation.

During the tour, the observation was confirmed by Staff CC.

A second tour of the psychiatric intensive care unit was conducted on 12/04/12 at 9:40 A.M. with Staff CC and DD. Staff was in attendance at the threshold of the door, of the multipurpose room but were unable to visualize the activity of the whole room.

During the tour, Staff DD confirmed the finding, and explained the hospital's expectation is staff are to monitor the patients every 15 minutes.

Based on observation and interview, the facility failed to ensure each door(s) protecting corridor openings resisted the passage of smoke. This affected the double doors in the lobby/kitchen area, and the doors in the outpatient area, and has the potential to affect all patients, staff, and visitors in the building. The census at the time of the survey was 69 patients.

Findings include:

A tour of the lobby area was included in the tour of the kitchen/dining area on 12/04/12 at 10:30 A.M. that was conducted with Staff CC. The tour revealed a set of double doors in the wall that separated the lobby from the main corridor. These doors were observed to have a gap mostly closed off with a rubber strip. The rubber strip had multiple gaps in it with the largest being two inches in length. Two other gaps were one inch in diameter.

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. (The outpatient area was within the building and used adjacent to a patient sleeping area.) During the tour, the area was observed to have an east/west corridor. At the east end of the corridor a door leading to the dayroom was observed to have half-inch holes in it. Another door leading to office space " A " was found to have a half-inch hole in it.

During the tour Staff CC confirmed the findings stating that after self closers had been removed from the doors, the holes that were left behind did not get filled.

Based on observation, and interview, the facility failed to ensure each door(s) protecting corridor openings resisted the passage of smoke. This affected the double doors in the lobby/kitchen area, and the doors in the outpatient area. This deficiency has the potential to affect all patients, staff, and visitors in the building. The census at the time of the survey was 69 patients.

Findings include:

A tour of the lobby area was included in the tour of the kitchen/dining area on 12/04/12 at 10:30 A.M., and was conducted with Staff CC. The tour revealed a set of double doors in the wall that separated the lobby from the main corridor. These doors were observed to have a gap mostly closed off by a rubber strip. The rubber strip had multiple gaps in it with the largest being two inches in length. Two other gaps were one inch in diameter.

A tour of the outpatient area was included with the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. (The outpatient area was within the building and used adjacent to a patient sleeping area.) During the tour, the area was observed to have an east/west corridor. At the east end of the corridor a door leading to the dayroom was observed to have half-inch holes in it. Another door, leading to office space " A " was observed to have a half-inch hole in it.

During the tour Staff CC confirmed the findings stating that after self closers had been removed from the doors, the holes that were left behind did not get filled.

Based on interview and record review, the facility failed to hold fire drills under varying conditions at unexpected times. This has the potential to affect all patients and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

Review of the facility ' s fire drills since 01/01/12 revealed they were conducted quarterly on each shift. The review revealed the second drill in each quarter was held between 3:00 P.M. and 3:30 P.M. The review revealed the third drill in each quarter was held between 6:55 A.M. and 7:02 A.M.

Review of the safety committee meeting minutes was completed on 12/06/12. The review revealed in January 2012 meeting a 2012 fire drill calendar. This calendar indicated the second drill in each quarter was to be held at 3:30 P.M., and the third drill in each quarter to be held at 7:00 A.M. The calendar does not speak to holding drills under varying conditions and unexpected times.

Based on interview, and record review, the facility failed to hold fire drills under varying conditions at unexpected times. This has the potential to affect all patients and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

Review of the facility's fire drill reports from 01/01/12 revealed they were conducted quarterly on each shift. The review revealed the second drill in each quarter was held between 3:00 P.M. and 3:30 P.M. The review revealed the third drill in each quarter was held between 6:55 A.M. and 7:02 A.M.

Review of the safety committee meeting minutes was completed on 12/06/12. The January Safety Committee minutes revealed a 2012 fire drill calendar. This calendar revealed the second drill in each quarter was to be held at 3:30 P.M., and the third drill in each quarter to be held at 7:00 A.M. The calendar did not speak to holding drills under varying conditions and unexpected times.

Based on observation and interview, the facility failed to continuously maintain its automatic sprinkler system in a reliable operating condition in accordance with the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18 New Health Care, and NFPA 13. This has the potential to affect all patients, staff and visitors in the facility. The census at the time of the survey was 69 patients.

Findings include:

A tour of the kitchen/dining area was conducted on 12/04/12 at 10:30 A.M. with Staff CC. Observation of the sprinkler heads in the dining area revealed six had a screw missing from the escutcheon such that the sprinkler head was not flush with the ceiling, two sprinkler headsmissing the escutcheon altogether, and three coated with dust and dirt.

During the tour, Staff CC confirmed the findings.

A tour of the lobby area was included in the tour of the kitchen/dining area on 12/04/12 at 10:30 A.M. that was conducted with Staff CC. Observation of this area revealed a mini-corridor that bisected an exam room and office spaces. Observation of one office space across from the exam room (indicated as room 181 on the schematic) revealed the office to have a sprinkler. Observation revealed books stacked within the 18 inch zone from the ceiling.

During the tour, Staff CC confirmed the finding.

Based on observation and interview, the facility failed to continuously maintain its automatic sprinkler system in a reliable operating condition in accordance with the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18 New Health Care, and NFPA 13. This has the potential to affect all patients, staff and visitors in the facility. The census at the time of the survey was 69 patients.

Findings include:

A tour of the kitchen/dining area was conducted on 12/04/12 at 10:30 A.M. with Staff CC. Observation of the sprinkler heads in the dining area revealed six that had had a screw missing from the escutcheon such that the sprinkler head was not flush with the ceiling, two missing the escutcheon altogether, and three coated with dust and dirt.

During the tour, Staff CC confirmed the findings.

A tour of the lobby area was included in the tour of the kitchen/dining area on 12/04/12 at 10:30 A.M. that was conducted with Staff CC. Observation of this area revealed a mini-corridor that bisected an exam room and office spaces. Observation of one office space across from the exam room (indicated as room 181 on the schematic) revealed the office to have a sprinkler. Observation revealed books stacked within the 18 inch zone from the ceiling.

During the tour, Staff CC confirmed the finding.

Based on interview and observation, the facility failed to ensure each fire extinguisher was readily accessible in accordance with NFPA 10. This has the potential to affect all patients, family and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

On 12/03/12 at 1:45 P.M. a tour of the psychiatric intensive care unit revealed fire extinguishers to be locked in cabinets within the walls of the facility. During the tour in an interview, Staff CC stated all the extinguishers in the facility were so secured.

On 12/03/12 at 2:20 P.M., during an interview Staff EE had difficulty finding the key for the fire extinguisher in the cabinet. (The surveyor observed the key to be very similar in size and shape to several other keys on the clinician ' s key ring.) Upon placing the key into the lock, Staff EE had difficulty opening the cabinet itself. Unlocking the cabinet required two steps: first, unlocking the lock with one hand, then flipping a latch with the other.

During the tour Staff CC confirmed the fire extinguisher key was similar to other keys on the key ring.

During the tour Staff FF also required assistance to locate the right key to the fire extinguisher cabinet.

Review of the facility ' s safety committee meeting minutes for 2012 was completed on 12/06/12. The review revealed during the 07/12/12 meeting 20 percent of sampled staff were unable to demonstrate how to remove the fire extinguishers from their cases.

Based on interview and observation, the facility failed to ensure each fire extinguisher was readily accessible in accordance with NFPA 10. This has the potential to affect all patients, family and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

On 12/03/12 at 1:45 P.M. a tour of the psychiatric intensive care unit revealed fire extinguishers to be locked in cabinets within the walls of the facility. Staff CC, when interviewed during the tour, stated all the extinguishers in the facility were so secured.

On 12/03/12 at 2:20 P.M., during an interview Staff EE had difficulty finding the key for the fire extinguisher in the cabinet. (The surveyor observed the key to be very similar in size and shape to several other keys on the clinician ' s key ring.) Upon placing the key into the lock, Staff EE had difficulty opening the cabinet itself. Unlocking the cabinet required two steps: first, unlocking the lock with one hand, then flipping a latch with the other.

During the tour Staff CC confirmed the fire extinguisher key was similar to other keys on the key ring.

During the tour Staff FF also required assistance to locate the right key to the fire extinguisher cabinet.

Review of the facility ' s safety committee meeting minutes for 2012 was completed on 12/06/12. The review revealed during the 07/12/12 meeting 20 percent of sampled staff were unable to demonstrate how to remove the fire extinguishers from their cases.

Based on observation and interview, the facility failed to ensure to ensure the building was free of portable space heating devices. This had the potential to affect all patients, visitors and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. (The outpatient area was within the building and used adjacent to a patient sleeping area.) Observation of space " A " revealed a space heater within.

During the tour, Staff CC confirmed the finding.

On 12/04/12 at 11:20 A.M. a tour was conducted of the crisis intervention unit with Staff CC and DD. During the tour an office was observed at the end of the north/south corridor, and perpendicular to the exit at the end of said corridor (designated p109 on the schematic). The office was observed to contain a space heater.

During the tour Staff CC confirmed the finding.

Based on observation and interview, the facility failed to ensure to ensure the building was free of portable space heating devices. This had the potential to affect all patients, visitors and staff in the facility. The census at the time of the survey was 69 patients.

Findings include:

A tour of the outpatient area was included in the tour of the psychiatric intensive care unit conducted on 12/03/12 at 1:45 P.M. with Staff CC. (The outpatient area, which is used, was located within the building and adjacent to a patient sleeping area.) Observation of space " A " revealed a space heater within.

During the tour, Staff CC confirmed the finding.

On 12/04/12 at 11:20 A.M. a tour was conducted of the crisis intervention unit with Staff CC and DD. During the tour an office was observed at the end of the north/south corridor, and perpendicular to the exit at the end of said corridor (designated p109 on the schematic). The office was observed to contain a space heater.

During the tour Staff CC confirmed the finding.

Based on observation and interview, the facility failed to ensure weekly generator inspections were documented. This has the potential to affect all patients, staff and visitors who use the facility. The census at the time of the survey was 69 patients.

Findings include:

A review of the facility ' s generator log for 2012 was completed on 12/06/12. The review did not reveal any documentation of a weekly visual inspection for items such as fuel level, coolant level, and condition of the battery.

On the morning of 12/06/12, Staff CC confirmed a log of a weekly visual generator checks were not done.

Based on observation and interview, the facility failed to ensure weekly generator inspections were documented. This has the potential to affect all patients, staff and visitors who use the facility. The census at the time of the survey was 69 patients.

Findings include:

A review of the facility's generator log for 2012 was completed on 12/06/12. The review did not reveal any documentation of a weekly visual inspection for items such as fuel level, coolant level, and condition of the battery.

On the morning of 12/06/12, Staff CC confirmed a log of a weekly visual generator checks were not done.

Based on observation and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular. This has the potential to affect all patients, staff, and visitors in the facility. The census at the time of the survey was 69 patients.

Findings:

On 12/03/12 at 1:45 P.M. a tour of the psychiatric intensive care unit revealed a charting room. Observation within the charting room revealed a 9 receptacle expansion pod with a 6 receptacle power strip plugged into it. Into the power strip there were three receptacles in use.

During the tour, Staff CC confirmed the observation.

Based on observation and interview, the facility failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular. This has the potential to affect all patients, staff, and visitors in the facility. The census at the time of the survey was 69 patients.

Findings:

On 12/03/12 at 1:45 P.M. a tour of the psychiatric intensive care unit revealed a charting room. Observation within the charting room revealed a 9 receptacle expansion pod with a 6 receptacle power strip plugged into it. There were three receptacles in use in the power strip.

During the tour, Staff CC confirmed the observation.