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It was determined by observation during the course of the survey on 10/05/2010, that the fire resistive rating of the building was not maintained in compliance with NFPA 101, as evidenced by the following:

1. Room #3047 on the third floor had four holes around penetrations in the ceiling, voiding the two hour fire resistive rating of the building.
2. Room #2047 on the second floor had mineral wool filling the hole around a conduit. There was no fire rated caulk to seal the opening and cover the mineral wool filling.

It was determined by observation and staff interview during the course of the survey on 10/05/2010, that doors in exit passage ways were not held open by approved devices in accordance with NFPA 101, as evidenced by the following:

The cross corridor doors between resident rooms #3054 and 3055 were both propped open with rubber chocks. Staff indicated that these doors must be open in order to have an unobstructed view of the residents in that section. In that case, the doors may be held open by magnetic hold open devices.

It was determined by observation during the course of the survey on 10/05/2010, that hazardous areas were not protected in compliance with NFPA 101, as evidenced by the following:

1. Room #2079 on the second floor contained a large quantity of combustible materials, exceeded 50 square feet and was not provided with a self-closing device.
2. The door to the first floor emergency supply room contained a large quantity of combustible materials, exceeded 50 square feet and was not provided with a self-closing device.
3. The door to the first floor housekeeping supply room was chocked open. The room contains large quantities of combustible storage. There was a self-closing device on the door, but it is rendered inoperable when the door is wedged open.

t was determined by observation during the course of the survey on 10/05/2010, that exits were not readily accessible at all times, as evidenced by the following:

1. The bathroom door outside the seclusion room on the Adult 2 unit cannot have a double-keyed dead bolt.
2. There was no exit access to the public way from the basement gymnasium. The doors to the exterior went to a small concrete pad with no sidewalk.

It was determined by observation and staff interview during the course of the survey on 10/05/2010, that bedroom doors could not be opened by residents from the inside in accordance with NFPA 101, as evidenced by the following:

The doors to patient rooms on the second and third floors were provided with deadbolt locks. These locks had blanks on the inside and there was no means of opening the doors to access the exit passageway. Staff indicated that these doors were only locked when the room is empty. This practice does not preclude the accidental locking of staff or residents inside the rooms. The exception in Chapter 19.2.2.2.2 does not apply, because the locking arrangements are not in the interest of the clinical needs of the residents.

It was determined by observation during the course of the survey on 10/05/2010, that smoking regulations were not enforced in accordance with NFPA 101, as evidenced by the following:

There was no self-closing metal container to be used as a receptacle for dumping ashtrays located in the designated smoking area.

It was determined by observation and staff interview during the course of the survey on 10/05/2010, that exits were not free from obstructions and that residents clinical needs were not involved in the locking arrangements provided, as evidenced by the following:

1. Three sets of cross-corridor doors on the second floor had locking devices. Staff indicated that the doors between rooms 3054 and 3055 needed to be propped open at times to make residents in the first compartment visible to the nurse's station. The doors as arranged on the day of the survey contradicted this reasoning because the rooms 2066 and 2069 were not visible from either nurse's station.

It was further determined that the intent of the Life Safety Code to allow doors within a means of egress to be locked for the clinical needs of the patients (NFPA 101, Chapter 19.2.2.2.4) was not met with the locking arrangements as they exist. The Code indicates that the staff must be able to readily unlock such doors. The exit access requires staff to open as many as five locks to provide safe egress to the public way. This condition does not make exit access readily available. It appears that the clinical needs of the residents could be met by locking any one of the three doors, but not any more than one.

2. Two sets of cross-corridor doors on the third floor had locking devices. It was determined that the intent of the Life Safety Code to allow doors within a means of egress to be locked for the clinical needs of the patients (NFPA 101, Chapter 19.2.2.2.4) was not met with the locking arrangements as they exist. The Code indicates that the staff must be able to readily unlock such doors. The exit access requires staff to open as many as four locks to provide safe egress to the public way. This condition does not make exit access readily available. It appears that the clinical needs of the residents could be met by locking any one of the two doors, but not any more than one.

3. It was further determined that stairways were not readily accessible. Doors were locked on each level. The stair doors to the exterior were also locked. The large courtyard was provided with a locked gate in the security fence around the perimeter of the area. The locking of the door at the bottom of the stairs or the locking of the doors on each level would meet the clinical needs of the residents and make the exits readily available to staff with keys. If the gate in the courtyard is to be locked then it must release with the activation of the fire alarm system as is the case with any exit access to the public way.

It was determined by observation during the course of the survey on 10/05/2010, that electrical wiring and equipment were not in accordance with the requirements of NFPA 70 and the Centers for Medicare and Medicaid Services, as evidenced by the following:

1. There was a coffee pot plugged into a power strip in the doctor's office #3054.
2. There was a fan plugged into a power strip in the Adult One nurse manager's office.
3. There was a fan and an extension cord plugged into a power strip in the first floor chart nursing office.
4. The change machine in the first floor staff lounge was plugged into a power strip.
5. The nurse's work room on adult two had a refrigerator serviced by an extension cord.
Only sensitive electronic equipment is permitted to be plugged into power surge protectors. Extension cords are not permitted to be used as a substitute for permanent wiring. This applies to items 1-5 above.
6. There was a duplex outlet with not GFCI protection built into the frame of the washing machine water line and waste in the adolescent wing laundry room.

It was determined by observation during the course of the survey on 10/05/2010, that alcohol base hand rub was not installed in accordance with NFPA 101 and Centers for Medicare and Medicaid Regulations, as evidenced by the following:

1. The gel dispenser in room #2072 was installed above an electrical light switch.
2. The gel dispenser in the second floor adult unit exam room was installed above an electrical light switch.

It was determined by observation during the course of the survey on 10/05/2010, that the fire resistive rating of the building was not maintained in compliance with NFPA 101, as evidenced by the following:

1. Room #3047 on the third floor had four holes around penetrations in the ceiling, voiding the two hour fire resistive rating of the building.
2. Room #2047 on the second floor had mineral wool filling the hole around a conduit. There was no fire rated caulk to seal the opening and cover the mineral wool filling.

It was determined by observation and staff interview during the course of the survey on 10/05/2010, that doors in exit passage ways were not held open by approved devices in accordance with NFPA 101, as evidenced by the following:

The cross corridor doors between resident rooms #3054 and 3055 were both propped open with rubber chocks. Staff indicated that these doors must be open in order to have an unobstructed view of the residents in that section. In that case, the doors may be held open by magnetic hold open devices.

It was determined by observation during the course of the survey on 10/05/2010, that hazardous areas were not protected in compliance with NFPA 101, as evidenced by the following:

1. Room #2079 on the second floor contained a large quantity of combustible materials, exceeded 50 square feet and was not provided with a self-closing device.
2. The door to the first floor emergency supply room contained a large quantity of combustible materials, exceeded 50 square feet and was not provided with a self-closing device.
3. The door to the first floor housekeeping supply room was chocked open. The room contains large quantities of combustible storage. There was a self-closing device on the door, but it is rendered inoperable when the door is wedged open.

t was determined by observation during the course of the survey on 10/05/2010, that exits were not readily accessible at all times, as evidenced by the following:

1. The bathroom door outside the seclusion room on the Adult 2 unit cannot have a double-keyed dead bolt.
2. There was no exit access to the public way from the basement gymnasium. The doors to the exterior went to a small concrete pad with no sidewalk.

It was determined by observation and staff interview during the course of the survey on 10/05/2010, that bedroom doors could not be opened by residents from the inside in accordance with NFPA 101, as evidenced by the following:

The doors to patient rooms on the second and third floors were provided with deadbolt locks. These locks had blanks on the inside and there was no means of opening the doors to access the exit passageway. Staff indicated that these doors were only locked when the room is empty. This practice does not preclude the accidental locking of staff or residents inside the rooms. The exception in Chapter 19.2.2.2.2 does not apply, because the locking arrangements are not in the interest of the clinical needs of the residents.

It was determined by observation during the course of the survey on 10/05/2010, that smoking regulations were not enforced in accordance with NFPA 101, as evidenced by the following:

There was no self-closing metal container to be used as a receptacle for dumping ashtrays located in the designated smoking area.

It was determined by observation and staff interview during the course of the survey on 10/05/2010, that exits were not free from obstructions and that residents clinical needs were not involved in the locking arrangements provided, as evidenced by the following:

1. Three sets of cross-corridor doors on the second floor had locking devices. Staff indicated that the doors between rooms 3054 and 3055 needed to be propped open at times to make residents in the first compartment visible to the nurse's station. The doors as arranged on the day of the survey contradicted this reasoning because the rooms 2066 and 2069 were not visible from either nurse's station.

It was further determined that the intent of the Life Safety Code to allow doors within a means of egress to be locked for the clinical needs of the patients (NFPA 101, Chapter 19.2.2.2.4) was not met with the locking arrangements as they exist. The Code indicates that the staff must be able to readily unlock such doors. The exit access requires staff to open as many as five locks to provide safe egress to the public way. This condition does not make exit access readily available. It appears that the clinical needs of the residents could be met by locking any one of the three doors, but not any more than one.

2. Two sets of cross-corridor doors on the third floor had locking devices. It was determined that the intent of the Life Safety Code to allow doors within a means of egress to be locked for the clinical needs of the patients (NFPA 101, Chapter 19.2.2.2.4) was not met with the locking arrangements as they exist. The Code indicates that the staff must be able to readily unlock such doors. The exit access requires staff to open as many as four locks to provide safe egress to the public way. This condition does not make exit access readily available. It appears that the clinical needs of the residents could be met by locking any one of the two doors, but not any more than one.

3. It was further determined that stairways were not readily accessible. Doors were locked on each level. The stair doors to the exterior were also locked. The large courtyard was provided with a locked gate in the security fence around the perimeter of the area. The locking of the door at the bottom of the stairs or the locking of the doors on each level would meet the clinical needs of the residents and make the exits readily available to staff with keys. If the gate in the courtyard is to be locked then it must release with the activation of the fire alarm system as is the case with any exit access to the public way.

It was determined by observation during the course of the survey on 10/05/2010, that electrical wiring and equipment were not in accordance with the requirements of NFPA 70 and the Centers for Medicare and Medicaid Services, as evidenced by the following:

1. There was a coffee pot plugged into a power strip in the doctor's office #3054.
2. There was a fan plugged into a power strip in the Adult One nurse manager's office.
3. There was a fan and an extension cord plugged into a power strip in the first floor chart nursing office.
4. The change machine in the first floor staff lounge was plugged into a power strip.
5. The nurse's work room on adult two had a refrigerator serviced by an extension cord.
Only sensitive electronic equipment is permitted to be plugged into power surge protectors. Extension cords are not permitted to be used as a substitute for permanent wiring. This applies to items 1-5 above.
6. There was a duplex outlet with not GFCI protection built into the frame of the washing machine water line and waste in the adolescent wing laundry room.