HospitalInspections.org

Building construction type does not meet the requirements of NFPA 101-2000, 19.1.6.2. Lack of required construction type can cause premature failure of the structural system causing building collapse prior to evacuation.

Findings include:

A. The Administration Building is indicated to be Type II (000) construction type. Portions of the Administration Building are 2-story and not fully sprinklered to comply with 19.1.6.2. Patients frequent only single story areas but the 2-story portion of the building was not indicated to be separated by 2-hour rated barriers from the single story portion utilized by patients. Therefore, the entire building was reviewed as a 2-story existing healthcare building which is not fully sprinklered to comply with 19.1.6.2.

Based on observation during the survey walk-through, not all corridor doors indicated to provide a fire resistance rated separation between building areas are installed in accordance with NFPA 101-2000, 19.3.6.3 and NFPA 80. These deficiencies could affect all patients adjacent to the barriers, as well as any staff and visitors present, by allowing smoke and fire to escape from either side of the barrier into the other side.

Findings include:

A. At 9:15am on 01/06/15 it was observed that the corridor wall, along the corridor serving the Dining Room and Snack Bar/Lounge, was indicated by available plans to be 1-hour fire resistance rated. Upon inspection not all doors in this wall, which included two pair of doors at the dining room, a pair of doors at the Snack Bar/Lounge, two toilet room doors and a janitor room door, met all the requirements for maintaining the 1-hour fire resistance rated barrier.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. At 8:30am on 01/06/15 it was observed that the Medical Records File Storage room located near the Security office and patient courtroom was not separated from adjacent areas in compliance with NFPA 101-2000, 19.3.2.1, 8.4.1.2, & 8.2.4.3.5 because the two doors (C-9 & C-13) at the sprinklered space were not self-closing.

B. At 9:00am on 01/06/15 it was observed that the Kitchen Dry Storage room located off the kitchen was not separated from adjacent areas in compliance with NFPA 101-2000, 19.3.2.1, 8.4.1. The unsprinklered storage room door E19 lacks self-closing, positive latching, minimum 3/4-hour rated door assembly to comply with 19.3.2.1, 8.4.1.1(1) and NFPA 80. This pair of doors was provided with friction hold-open devices and louvers.

Based on observation and staff interview during the survey walk-through on 01/06/15, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. At 10:30am on 01/06/15 it was observed that exit discharge lighting is not provided at all exterior doors identified as exits. Observed location(s) include the doors directly to the exterior from the nurse station area.

Based on observation and staff interview during the survey walk-through on 01/06/15, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. At 10:45am on 01/06/15 it was observed that exit discharge lighting in accordance with 7.8.1.4 and 7.9.2 is not provided at all exterior doors. High pressure sodium lighting was indicated and observed to be provided at the porch exterior door location which is not of the instant-on type.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 10:00am on 01/06/15 it was observed that the exit sign at the exterior door of the patient room corridor is not fully visible from all points in the corridor. The mounting height and surface mounted corridor lighting fixtures obstruct visibility.

B. At 10:00am on 01/06/15 it was observed that the exit sign, at the nurse station side of the smoke barrier doors, to identify the required 2nd means of egress from the day room area was removed.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 10:15am on 01/06/15 it was observed that exit signage is not provided in the patient room corridor to identify two available exit routes. The corridor lacks exit signage at both ends of the corridor.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 10:30am on 01/06/15 it was observed that exit signage at the exterior door of the patient room corridor is not fully visible from all points within the corridor to identify two available exit routes. Visibility is obstructed by ceiling height changes and other surface mounted light fixtures.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 9:45am on 01/06/15 it was observed that exit signage at the patient room corridor is not fully visible from all points within the corridor to identify two available exit routes. Visibility is obstructed by ceiling height changes and other surface mounted light fixtures.

The facility's written fire plan policy does not include key components for Procedures in Case of Fire in accordance with NFPA 101-2000, 19.7.2. Failure to have a clear plan for response to a fire condition can jeopardize occupant safety and/or evacuation procedures.

Findings include:

A. The fire plan is not specific to the security employed at this mental health facility relative to the use of keys for egress to adjacent smoke compartments or building evacuation. The fire plan does not address all of the following in accordance with NFPA 101-2000, 19.7.2.2:

1) Use of alarms
2) Transmission of alarm to fire department
3) Response to alarms
4) Isolation of fire
5) Evacuation of immediate area
6) Evacuation of smoke compartment (or relocation to a safer area of the building) (Surveyor notes that facility information indicates that smoke barriers are noted to be deficient above the ceiling, but the barriers are not required under NFPA 101-2000, 19.3.7.1.)
7) Preparation of floors and building for evacuation
8) Extinguishment of fire

B. The Interim Life Safety Measures policy is not specific to address the "locked" condition at this facility. References are made that "free and unobstructed egress must be maintained", but the facility utilizes locked doors through-out which are designed to restrict/control egress.

The facility's written fire plan policy does not include key components for Procedures in Case of Fire in accordance with NFPA 101-2000, 19.7.2. Failure to have a clear plan for response to a fire condition can jeopardize occupant safety and/or evacuation procedures.

Findings include:

A. The fire plan is not specific to the security employed at this mental health facility relative to the use of keys for egress to adjacent smoke compartments or building evacuation. The fire plan does not address all of the following in accordance with NFPA 101-2000, 19.7.2.2:

1) Use of alarms
2) Transmission of alarm to fire department
3) Response to alarms
4) Isolation of fire
5) Evacuation of immediate area
6) Evacuation of smoke compartment (or relocation to safer area of the building) (Surveyor notes that facility information indicates that smoke barriers are noted to be deficient above the ceiling, but the barriers are not required under NFPA 101-2000, 19.3.7.1.)
7) Preparation of floors and building for evacuation
8) Extinguishment of fire

B. The Interim Life Safety Measures policy is not specific to address the "locked" condition at this facility. References are made that "free and unobstructed egress must be maintained", but the facility utilizes locked doors through-out which are designed to restrict/control egress.

The facility's written fire plan policy does not include key components for Procedures in Case of Fire in accordance with NFPA 101-2000, 19.7.2. Failure to have a clear plan for response to a fire condition can jeopardize occupant safety and/or evacuation procedures.

Findings include:

A. The fire plan is not specific to the security employed at this mental health facility relative to the use of keys for egress to adjacent smoke compartments or building evacuation. The fire plan does not address all of the following in accordance with NFPA 101-2000, 19.7.2.2:

1) Use of alarms
2) Transmission of alarm to fire department
3) Response to alarms
4) Isolation of fire
5) Evacuation of immediate area
6) Evacuation of smoke compartment (or relocation to safer area of the building)(Surveyor notes that facility information indicates that smoke barriers are noted to be deficient above the ceiling, but the barriers are not required under NFPA 101-2000, 19.3.7.1.)
7) Preparation of floors and building for evacuation
8) Extinguishment of fire

B. The Interim Life Safety Measures policy is not specific to address the "locked" condition at this facility. References are made that "free and unobstructed egress must be maintained", but the facility utilizes locked doors through-out which are designed to restrict/control egress.

The facility's written fire plan policy does not include key components for Procedures in Case of Fire in accordance with NFPA 101-2000, 19.7.2. Failure to have a clear plan for response to a fire condition can jeopardize occupant safety and/or evacuation procedures.

Findings include:

A. The fire plan is not specific to the security employed at this mental health facility relative to the use of keys for egress to adjacent smoke compartments or building evacuation. The fire plan does not address all of the following in accordance with NFPA 101-2000, 19.7.2.2:

1) Use of alarms
2) Transmission of alarm to fire department
3) Response to alarms.
4) Isolation of fire
5) Evacuation of immediate area
6) Evacuation of smoke compartment (or relocation to safer area of the building)(Surveyor notes that facility information indicates that smoke barriers are noted to be deficient above the ceiling, but the barriers are not required under NFPA 101-2000, 19.3.7.1.)
7) Preparation of floors and building for evacuation
8) Extinguishment of fire

B. The Interim Life Safety Measures policy is not specific to address the "locked" condition at this facility. References are made that "free and unobstructed egress must be maintained", but the facility utilizes locked doors through-out which are designed to restrict/control egress.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. Fire drills for each building is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Monroe Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:15 on 11/06/14
At 13:40 on 08/20/14
At 10:59 on 05/28/14
At 13:08 on 02/13/14

Three of four quarters were conducted within the same 1 ½ hour period of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 17:58 on 12/27/14
At 19:20 on 09/30/14
At 18:45 on 06/25/14
At 19:04 on 03/26/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:16 on 10/28/14
At 06:11 on 07/29/14
At 06:10 on 04/29/14
At 06:07 on 01/16/14

Four of four quarters were conducted within the same half hour period at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. Fire drills for each of the building is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Jefferson Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:08 on 11/06/14
At 13:45 on 08/20/14
At 10:40 on 05/28/14
At 13:09 on 02/13/14

Three of four quarters were conducted within the same hour of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 17:48 on 12/27/14
At 19:10 on 09/30/14
At 18:29 on 06/25/14
At 18:54 on 03/26/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for 3rd shift employees were conducted as follows:

At 06:00 on 10/28/14
At 06:06 on 07/29/14
At 06:01 on 04/29/14
At 06:00 on 01/16/14

Four of four quarters were conducted within the same hour at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Stevenson Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:02 on 11/06/14
At 13:58 on 08/20/14
At 10:31 on 05/28/14
At 13:00 on 02/13/14

Three of four quarters were conducted within the same hour of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 17:44 on 12/27/14
At 19:00 on 09/30/14
At 18:13 on 06/25/14
At 18:45 on 03/26/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:11 on 10/28/14
At 06:01 on 07/29/14
At 05:57 on 04/29/14
At 05:55 on 01/16/14

Four of four quarters were conducted within the same half hour period at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Kennedy Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:35 on 11/06/14
At 12:45 on 08/20/14
At 10:30 on 05/28/14
At 13:13 on 02/13/14

Three of four quarters were conducted within the same 1 ½ hour period of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 18:25 on 12/27/14
At 20:15 on 09/30/14
At 19:29 on 06/25/14
At 19:12 on 03/26/14

Three of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:45 on 10/28/14
At 06:26 on 07/29/14
At 06:37 on 04/29/14
At 06:35 on 01/16/14

Four of four quarters were conducted within the same half hour at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Administration Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:45 on 11/06/14
At 14:14 on 08/20/14
At 14:28 on 05/07/14
At 13:25 on 02/13/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 17:00 on 01/01/15
At 20:40 on 09/30/14
At 19:45 on 06/25/14
At 19:40 on 03/26/14

Three of four quarters were conducted within the same one hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:50 on 10/28/14
At 05:51 on 07/29/14
At 06:48 on 04/29/14
At 06:45 on 01/16/14

Four of four quarters were conducted within the same one hour period at the end of the shift. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Lincoln North Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:30 on 11/06/14
At 13:14 on 08/20/14
At 10:26 on 05/28/14
At 12:58 on 02/13/14

Three of four quarters were conducted within the same 1 ½ hour period of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 19:03 on 12/27/14
At 19:45 on 09/30/14
At 19:03 on 06/25/14
At 19:21 on 03/26/14

Four of four quarters were conducted within the same hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:37 on 10/28/14
At 06:21 on 07/29/14
At 06:27 on 04/29/14
At 06:20 on 01/16/14

Four of four quarters were conducted within the same half hour at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Lincoln South Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:25 on 11/06/14
At 13:29 on 08/20/14
At 10:46 on 5/28/14
At 12:59 on 02/13/14

Three of four quarters were conducted within the same 1 ½ hour period of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:
At 18:09 on 12/27/14
At 19:35 on 09/30/14
At 18:53 on 06/25/14
At 19:30 on 03/26/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:
At 06:27 on 10/28/14
At 06:15 on 07/29/14
At 06:17 on 04/29/14
At 06:13 on 01/16/14

Four of four quarters were conducted within the same half hour at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

A. By direct observation on 01/06/15 at 10:00AM while accompanied by the Facility's Chief Engineer the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

A. By direct observation on 01/06/15 at 10:30AM while accompanied by the Facility's Chief Engineer the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

A. By direct observation on 01/06/15 at 11:00AM while accompanied by the Facility's Chief Engineer, the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)
3. Automatic smoke detection at the fire alarm control panel. (NFPA 72, 1999, 1- 5.6

A. By direct observation on 01/06/15 at 9:30AM while accompanied by the Facility's Chief Engineer the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

A. By direct observation on 01/06/15 at 9:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

A. By direct observation on 1/6/15 at 10:15AM while accompanied by the Facility's Chief Engineer the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 19.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1. Lack of maintenance for fire protection system could result in delayed response of those systems to provide required protection.

Findings include:

A. At 9:00am on 01/06/15 it was observed that the sprinkler protection provided at the Janitor room E-30, located between the toilet rooms near the dining room, was compromised by a hole cut in the ceiling to access the above ceiling space. The open ceiling can compromise the activation of the sprinkler protection provided for the room.

A. By direct observation and staff interview on 1/6/15 at 8:45AM while accompanied by the Facility's Chief Engineer, the surveyor finds the facility had fire dampers installed within the kitchen grease duct system in non-compliance with NFPA 96, 1998, 6-1.
B. By direct observation on 01/06/15 at 8:45AM while accompanied by the Facility's Chief Engineer, the surveyor found the kitchen grease hood's filters coated with grease and lint and in need of cleaning. (NFPA 96, 1998 8-3.1)

A. By direct observation and staff interview on 01/06/15 at 10:00AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 10:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 1/6/15 at 10:15AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 10:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 11:30AM while accompanied by the Facility's Chief Engineer, the surveyor finds the facility failed to provide the following:
1. A remote manual emergency stop station for the emergency generator. (NFPA 110, 1999, 3-5.5.6)
2. A remote alarm annunciator for the emergency generator at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)
3. Battery charger connections in compliance with NFPA 110, 1999, 5-12.6. The observed connections are direct to the battery terminals which do not comply with the requirement.
4. Starting battery heater w/auto shutoff for the emergency generator. (NFPA 110, 3-3.1).
B. By direct observation and staff interview on 01/06/15 at 11:00AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 9:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 9:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By staff interview on 01/06/15 at 9:00AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

By direct observation and staff interview on 1/6/15 at 10:00AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 10:15AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 10:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 10:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 11:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 9:00AMwhile accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 9:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at :9:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

Building construction type does not meet the requirements of NFPA 101-2000, 19.1.6.2. Lack of required construction type can cause premature failure of the structural system causing building collapse prior to evacuation.

Findings include:

A. The Administration Building is indicated to be Type II (000) construction type. Portions of the Administration Building are 2-story and not fully sprinklered to comply with 19.1.6.2. Patients frequent only single story areas but the 2-story portion of the building was not indicated to be separated by 2-hour rated barriers from the single story portion utilized by patients. Therefore, the entire building was reviewed as a 2-story existing healthcare building which is not fully sprinklered to comply with 19.1.6.2.

Based on observation during the survey walk-through, not all corridor doors indicated to provide a fire resistance rated separation between building areas are installed in accordance with NFPA 101-2000, 19.3.6.3 and NFPA 80. These deficiencies could affect all patients adjacent to the barriers, as well as any staff and visitors present, by allowing smoke and fire to escape from either side of the barrier into the other side.

Findings include:

A. At 9:15am on 01/06/15 it was observed that the corridor wall, along the corridor serving the Dining Room and Snack Bar/Lounge, was indicated by available plans to be 1-hour fire resistance rated. Upon inspection not all doors in this wall, which included two pair of doors at the dining room, a pair of doors at the Snack Bar/Lounge, two toilet room doors and a janitor room door, met all the requirements for maintaining the 1-hour fire resistance rated barrier.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors.

Findings include:

A. At 8:30am on 01/06/15 it was observed that the Medical Records File Storage room located near the Security office and patient courtroom was not separated from adjacent areas in compliance with NFPA 101-2000, 19.3.2.1, 8.4.1.2, & 8.2.4.3.5 because the two doors (C-9 & C-13) at the sprinklered space were not self-closing.

B. At 9:00am on 01/06/15 it was observed that the Kitchen Dry Storage room located off the kitchen was not separated from adjacent areas in compliance with NFPA 101-2000, 19.3.2.1, 8.4.1. The unsprinklered storage room door E19 lacks self-closing, positive latching, minimum 3/4-hour rated door assembly to comply with 19.3.2.1, 8.4.1.1(1) and NFPA 80. This pair of doors was provided with friction hold-open devices and louvers.

Based on observation and staff interview during the survey walk-through on 01/06/15, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. At 10:30am on 01/06/15 it was observed that exit discharge lighting is not provided at all exterior doors identified as exits. Observed location(s) include the doors directly to the exterior from the nurse station area.

Based on observation and staff interview during the survey walk-through on 01/06/15, not all exit discharge locations are provided with illumination to comply with 19.2.8, 7.8 and 7.9. This deficiency could affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

Findings include:

A. At 10:45am on 01/06/15 it was observed that exit discharge lighting in accordance with 7.8.1.4 and 7.9.2 is not provided at all exterior doors. High pressure sodium lighting was indicated and observed to be provided at the porch exterior door location which is not of the instant-on type.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 10:00am on 01/06/15 it was observed that the exit sign at the exterior door of the patient room corridor is not fully visible from all points in the corridor. The mounting height and surface mounted corridor lighting fixtures obstruct visibility.

B. At 10:00am on 01/06/15 it was observed that the exit sign, at the nurse station side of the smoke barrier doors, to identify the required 2nd means of egress from the day room area was removed.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 10:15am on 01/06/15 it was observed that exit signage is not provided in the patient room corridor to identify two available exit routes. The corridor lacks exit signage at both ends of the corridor.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 10:30am on 01/06/15 it was observed that exit signage at the exterior door of the patient room corridor is not fully visible from all points within the corridor to identify two available exit routes. Visibility is obstructed by ceiling height changes and other surface mounted light fixtures.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress in accordance with 19.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. At 9:45am on 01/06/15 it was observed that exit signage at the patient room corridor is not fully visible from all points within the corridor to identify two available exit routes. Visibility is obstructed by ceiling height changes and other surface mounted light fixtures.

The facility's written fire plan policy does not include key components for Procedures in Case of Fire in accordance with NFPA 101-2000, 19.7.2. Failure to have a clear plan for response to a fire condition can jeopardize occupant safety and/or evacuation procedures.

Findings include:

A. The fire plan is not specific to the security employed at this mental health facility relative to the use of keys for egress to adjacent smoke compartments or building evacuation. The fire plan does not address all of the following in accordance with NFPA 101-2000, 19.7.2.2:

1) Use of alarms
2) Transmission of alarm to fire department
3) Response to alarms
4) Isolation of fire
5) Evacuation of immediate area
6) Evacuation of smoke compartment (or relocation to a safer area of the building) (Surveyor notes that facility information indicates that smoke barriers are noted to be deficient above the ceiling, but the barriers are not required under NFPA 101-2000, 19.3.7.1.)
7) Preparation of floors and building for evacuation
8) Extinguishment of fire

B. The Interim Life Safety Measures policy is not specific to address the "locked" condition at this facility. References are made that "free and unobstructed egress must be maintained", but the facility utilizes locked doors through-out which are designed to restrict/control egress.

The facility's written fire plan policy does not include key components for Procedures in Case of Fire in accordance with NFPA 101-2000, 19.7.2. Failure to have a clear plan for response to a fire condition can jeopardize occupant safety and/or evacuation procedures.

Findings include:

A. The fire plan is not specific to the security employed at this mental health facility relative to the use of keys for egress to adjacent smoke compartments or building evacuation. The fire plan does not address all of the following in accordance with NFPA 101-2000, 19.7.2.2:

1) Use of alarms
2) Transmission of alarm to fire department
3) Response to alarms
4) Isolation of fire
5) Evacuation of immediate area
6) Evacuation of smoke compartment (or relocation to safer area of the building) (Surveyor notes that facility information indicates that smoke barriers are noted to be deficient above the ceiling, but the barriers are not required under NFPA 101-2000, 19.3.7.1.)
7) Preparation of floors and building for evacuation
8) Extinguishment of fire

B. The Interim Life Safety Measures policy is not specific to address the "locked" condition at this facility. References are made that "free and unobstructed egress must be maintained", but the facility utilizes locked doors through-out which are designed to restrict/control egress.

The facility's written fire plan policy does not include key components for Procedures in Case of Fire in accordance with NFPA 101-2000, 19.7.2. Failure to have a clear plan for response to a fire condition can jeopardize occupant safety and/or evacuation procedures.

Findings include:

A. The fire plan is not specific to the security employed at this mental health facility relative to the use of keys for egress to adjacent smoke compartments or building evacuation. The fire plan does not address all of the following in accordance with NFPA 101-2000, 19.7.2.2:

1) Use of alarms
2) Transmission of alarm to fire department
3) Response to alarms
4) Isolation of fire
5) Evacuation of immediate area
6) Evacuation of smoke compartment (or relocation to safer area of the building)(Surveyor notes that facility information indicates that smoke barriers are noted to be deficient above the ceiling, but the barriers are not required under NFPA 101-2000, 19.3.7.1.)
7) Preparation of floors and building for evacuation
8) Extinguishment of fire

B. The Interim Life Safety Measures policy is not specific to address the "locked" condition at this facility. References are made that "free and unobstructed egress must be maintained", but the facility utilizes locked doors through-out which are designed to restrict/control egress.

The facility's written fire plan policy does not include key components for Procedures in Case of Fire in accordance with NFPA 101-2000, 19.7.2. Failure to have a clear plan for response to a fire condition can jeopardize occupant safety and/or evacuation procedures.

Findings include:

A. The fire plan is not specific to the security employed at this mental health facility relative to the use of keys for egress to adjacent smoke compartments or building evacuation. The fire plan does not address all of the following in accordance with NFPA 101-2000, 19.7.2.2:

1) Use of alarms
2) Transmission of alarm to fire department
3) Response to alarms.
4) Isolation of fire
5) Evacuation of immediate area
6) Evacuation of smoke compartment (or relocation to safer area of the building)(Surveyor notes that facility information indicates that smoke barriers are noted to be deficient above the ceiling, but the barriers are not required under NFPA 101-2000, 19.3.7.1.)
7) Preparation of floors and building for evacuation
8) Extinguishment of fire

B. The Interim Life Safety Measures policy is not specific to address the "locked" condition at this facility. References are made that "free and unobstructed egress must be maintained", but the facility utilizes locked doors through-out which are designed to restrict/control egress.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. Fire drills for each building is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Monroe Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:15 on 11/06/14
At 13:40 on 08/20/14
At 10:59 on 05/28/14
At 13:08 on 02/13/14

Three of four quarters were conducted within the same 1 ½ hour period of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 17:58 on 12/27/14
At 19:20 on 09/30/14
At 18:45 on 06/25/14
At 19:04 on 03/26/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:16 on 10/28/14
At 06:11 on 07/29/14
At 06:10 on 04/29/14
At 06:07 on 01/16/14

Four of four quarters were conducted within the same half hour period at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. Fire drills for each of the building is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Jefferson Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:08 on 11/06/14
At 13:45 on 08/20/14
At 10:40 on 05/28/14
At 13:09 on 02/13/14

Three of four quarters were conducted within the same hour of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 17:48 on 12/27/14
At 19:10 on 09/30/14
At 18:29 on 06/25/14
At 18:54 on 03/26/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for 3rd shift employees were conducted as follows:

At 06:00 on 10/28/14
At 06:06 on 07/29/14
At 06:01 on 04/29/14
At 06:00 on 01/16/14

Four of four quarters were conducted within the same hour at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:

A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Stevenson Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:02 on 11/06/14
At 13:58 on 08/20/14
At 10:31 on 05/28/14
At 13:00 on 02/13/14

Three of four quarters were conducted within the same hour of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 17:44 on 12/27/14
At 19:00 on 09/30/14
At 18:13 on 06/25/14
At 18:45 on 03/26/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:11 on 10/28/14
At 06:01 on 07/29/14
At 05:57 on 04/29/14
At 05:55 on 01/16/14

Four of four quarters were conducted within the same half hour period at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Kennedy Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:35 on 11/06/14
At 12:45 on 08/20/14
At 10:30 on 05/28/14
At 13:13 on 02/13/14

Three of four quarters were conducted within the same 1 ½ hour period of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 18:25 on 12/27/14
At 20:15 on 09/30/14
At 19:29 on 06/25/14
At 19:12 on 03/26/14

Three of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:45 on 10/28/14
At 06:26 on 07/29/14
At 06:37 on 04/29/14
At 06:35 on 01/16/14

Four of four quarters were conducted within the same half hour at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Administration Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:45 on 11/06/14
At 14:14 on 08/20/14
At 14:28 on 05/07/14
At 13:25 on 02/13/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 17:00 on 01/01/15
At 20:40 on 09/30/14
At 19:45 on 06/25/14
At 19:40 on 03/26/14

Three of four quarters were conducted within the same one hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:50 on 10/28/14
At 05:51 on 07/29/14
At 06:48 on 04/29/14
At 06:45 on 01/16/14

Four of four quarters were conducted within the same one hour period at the end of the shift. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Lincoln North Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:30 on 11/06/14
At 13:14 on 08/20/14
At 10:26 on 05/28/14
At 12:58 on 02/13/14

Three of four quarters were conducted within the same 1 ½ hour period of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:

At 19:03 on 12/27/14
At 19:45 on 09/30/14
At 19:03 on 06/25/14
At 19:21 on 03/26/14

Four of four quarters were conducted within the same hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:

At 06:37 on 10/28/14
At 06:21 on 07/29/14
At 06:27 on 04/29/14
At 06:20 on 01/16/14

Four of four quarters were conducted within the same half hour at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

Based on record review and staff interview it was determined that the facility did not conduct fire drills in accordance with 19.7.1.2. Drills were not conducted at least quarterly on each shift under varied conditions to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action as required.

Findings include:
A. Fire drills for each of the buildings is typically conducted monthly on the same day. Each of three shifts is drilled once per quarter. However, drills are not conducted at varying times during each shift as indicated below for the Lincoln South Unit Building:

1. Fire drills conducted for 1st shift employees were conducted as follows:

At 14:25 on 11/06/14
At 13:29 on 08/20/14
At 10:46 on 5/28/14
At 12:59 on 02/13/14

Three of four quarters were conducted within the same 1 ½ hour period of the day at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

2. Fire drills conducted for the 2nd shift employees were conducted as follows:
At 18:09 on 12/27/14
At 19:35 on 09/30/14
At 18:53 on 06/25/14
At 19:30 on 03/26/14

Four of four quarters were conducted within the same 1 ½ hour period at a mid-shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

3. Fire drills conducted for the 3rd shift employees were conducted as follows:
At 06:27 on 10/28/14
At 06:15 on 07/29/14
At 06:17 on 04/29/14
At 06:13 on 01/16/14

Four of four quarters were conducted within the same half hour at the end of the shift time period. Therefore, not meeting the requirement of being held at unexpected times and under varying conditions as required by 19.7.1.2.

B. During document review, it was observed that the facility does not document that the fire alarm signal has been successfully transmitted to the monitoring agency as part of the drill activities to comply with 19.7.2.2.

A. By direct observation on 01/06/15 at 10:00AM while accompanied by the Facility's Chief Engineer the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

A. By direct observation on 01/06/15 at 10:30AM while accompanied by the Facility's Chief Engineer the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

A. By direct observation on 01/06/15 at 11:00AM while accompanied by the Facility's Chief Engineer, the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)
3. Automatic smoke detection at the fire alarm control panel. (NFPA 72, 1999, 1- 5.6

A. By direct observation on 01/06/15 at 9:30AM while accompanied by the Facility's Chief Engineer the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

A. By direct observation on 01/06/15 at 9:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

A. By direct observation on 1/6/15 at 10:15AM while accompanied by the Facility's Chief Engineer the surveyor find the facility failed to provide the following:
1. Provide indication, at the fire alarm control panel, as to the electrical panel and circuit number providing power to the panel. (NFPA 72, 1999, 1-5.2.5.2)
2. Provide identification in red and a lock-on device for the circuit disconnecting means for the fire alarm control panel. (NFPA 72, 1999, 1-5.2.5.2)

Based on observation during the survey walk-through, the facility failed to install and maintain automatic sprinkler protection in accordance with the requirements of NFPA 101-2000, 19.3.5, NFPA 13-1999, Chapter 5 and NFPA 25-1998, 2-2.1.1. Lack of maintenance for fire protection system could result in delayed response of those systems to provide required protection.

Findings include:

A. At 9:00am on 01/06/15 it was observed that the sprinkler protection provided at the Janitor room E-30, located between the toilet rooms near the dining room, was compromised by a hole cut in the ceiling to access the above ceiling space. The open ceiling can compromise the activation of the sprinkler protection provided for the room.

A. By direct observation and staff interview on 1/6/15 at 8:45AM while accompanied by the Facility's Chief Engineer, the surveyor finds the facility had fire dampers installed within the kitchen grease duct system in non-compliance with NFPA 96, 1998, 6-1.
B. By direct observation on 01/06/15 at 8:45AM while accompanied by the Facility's Chief Engineer, the surveyor found the kitchen grease hood's filters coated with grease and lint and in need of cleaning. (NFPA 96, 1998 8-3.1)

A. By direct observation and staff interview on 01/06/15 at 10:00AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 10:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 1/6/15 at 10:15AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 10:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 11:30AM while accompanied by the Facility's Chief Engineer, the surveyor finds the facility failed to provide the following:
1. A remote manual emergency stop station for the emergency generator. (NFPA 110, 1999, 3-5.5.6)
2. A remote alarm annunciator for the emergency generator at a constantly attended work station. NFPA 99, 1999, 3-4.1.1.15 (b)
3. Battery charger connections in compliance with NFPA 110, 1999, 5-12.6. The observed connections are direct to the battery terminals which do not comply with the requirement.
4. Starting battery heater w/auto shutoff for the emergency generator. (NFPA 110, 3-3.1).
B. By direct observation and staff interview on 01/06/15 at 11:00AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 9:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By direct observation and staff interview on 01/06/15 at 9:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

A. By staff interview on 01/06/15 at 9:00AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility failed to provide a Type 1 Essential Electric System (EES) in compliance with NFPA 99, 1999, 3-4. The facility's alternate source of power is a 900 KW diesel generator which has one transfer switch and supplies electricity to the entire facility in the event of a utility outage.

By direct observation and staff interview on 1/6/15 at 10:00AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 10:15AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 10:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 10:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 11:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 9:00AMwhile accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at 9:30AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).

By direct observation and staff interview on 1/6/15 at :9:45AM while accompanied by the Facility's Chief Engineer the surveyor finds the facility is not divided into the required Emergency System (3-5.2.2.2) and the Critical System (3-5.2.2.3).