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Based on observation and interview, the facility failed to ensure 1 of 1 "Regional Mental Health Center" fire barriers to a nonconforming occupancy was protected by a two hour fire rating. LSC 19.1.2.1 states sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours.
This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on observation with the Supervisor of General Services on 12/8/15 at 12:24 a.m., the wall which separates the "Regional Mental Health Center" on the second floor and the business offices on the second floor, a nonconforming occupancy, did not have any rating tags on either exit doors which open to the business offices. Based on interview at the time of observation, the Supervisor of General Services acknowledged the doors did not indicate an hourly rating tag and confirmed no cite plans were available for review for the construction of the walls.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier wall was protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on observations with the Supervisor of General Services on 12/8/15 at 12:34 p.m., the smoke barrier wall near the West Exit had two unsealed penetrations. Above the ceiling tile was the unsealed penetration which was a one eighth of an inch. Also, above the ceiling tiles was an unsealed penetration around sprinkler pipe measuring one eighth of an inch. Based on interview at the time of observation, the Supervisor of General Services acknowledged the aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 soiled linen storage room, a hazardous area, was provided with self closer and would latch into the frame. This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on observation with the Supervisor of General Services on 12/8/15 at 12:22 p.m., the corridor door to the only soiled linen storage room contained one very large container without a lid. Inside the container was a bag of soiled linen. Based on interview at the time of observation, the Supervisor of General Services could not provide an estimation of how many gallons the very large container could hold, but confirmed the very large container could store more than 32 gallons and confirmed this room was used for soiled linen storage.

Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 3 exits was readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect all staff, visitors, and patients.
Findings include:
Based on observation with the Supervisor of General Services on 12/8/15 at 11:47 a.m., the "Exit To Deck" door had an exit sign above it. Continuing through the discharge was a patio which led to a door, which led down a few stairs without a ramp, then to grass to the parking lot. Based on interview at the time of observation, the Supervisor of General Services acknowledged the aforementioned condition and confirmed that path was considered an exit.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift for 2 of the last 4 calendar quarters. This deficient practice could affect all staff and patients.
Findings include:
Based on record review with the Supervisor of General Services of the fire drill reports titled "Fire Drill Report Form" on 12/8/15 at 10:21 a.m., the documentation for a second shift fire drill for the third and fourth quarter of 2015 and a third shift fire drill for the fourth quarter of 2015 was not available for review. Based on interview at the time of record review, the Supervisor of General Services acknowledged the lack of documentation.

Based on record review and interview, the facility failed to ensure 32 of 32 smoke detectors were maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. This deficient practice could affect all staff, patients, and visitors.

Findings include:

Based on record review with the Supervisor of General Services on 12/8/15 at 10:21 a.m., a smoke detector sensitivity test was not available for review. Based on an interview with Supervisor of General Services at the time of record review, no other documentation was available for review.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic sprinkler piping systems was inspected every five years as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. Section 10-2.2, Obstruction Prevention, states systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on review of sprinkler system documentation with the Supervisor of General Services on 12/8/15 at 10:20 a.m., none of the quarterly sprinkler system inspection and testing records indicated an internal inspection of the sprinkler system pipes had been conducted. Based on interview at the time of record review, the Supervisor of General Services acknowledged the aforementioned condition.


2. Based on observation and interview, the facility failed to replace 4 of 6 bathroom corroded sprinkler heads in 6 bathrooms and 2 of 2 painted recessed sprinkler head covers in room E206. LSC 33.2.3.5.2 refers to LSC section 9.7. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1998 edition, 2-2.1.1 requires any sprinkler shall be replaced which is painted, corroded, damaged, loaded, or in the improper orientation. This deficient practice could affect staff and up to 5 patients.

Findings include:

Based on observation with the Supervisor of General Services on 12/8/15 between 11:55 a.m. and 12:01 p.m., the Supervisor of General Services confirmed four out of six bathrooms had one corroded sprinkler head in each. Also, the Soothing Room E206 contained two recessed sprinkler heads covers. Both recessed sprinkler head covers were painted. Based on interview at the time of observation, the Supervisor of General Services acknowledged the aforementioned conditions.

1. Based on observation and interview, the facility failed to ensure 1 of 1 generator was in accordance with NFPA 110, The Standard for Emergency and Standby Power Systems, Section 6-4.2.2 requires Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. This deficient practice could affect all staff, patients, and visitors.

Findings include:

Based on record review with the Supervisor of General Services on 12/8/15 at 9:42 a.m., the monthly generator forms failed to include the generator load percentage. Based on interview at the time of record review, the Supervisor of General Services acknowledged the aforementioned condition and confirmed that documentation for an annual load bank test was not available for review.


2. Based on record review and interview, the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test. LSC 19.2.9.1 refers to LSC 7.9 which refers to LSC 7.9.2.3 which requires generators to be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems,1999 Edition. NFPA 110, 4-2.4.8 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on review of the facility's Emergency Generator monthly testing log with the Supervisor of General Services on 12/8/15 at 9:42 a.m., the generator log form failed to document the generator cool down time following its load test. During interview at the time of record review, the Supervisor of General Services acknowledged the aforementioned condition and said the generator "runs for 25 minutes with a 5 minute cool down".

Based on observation and interview, the facility failed to ensure 1 of 1 electrical junction boxes observed was maintained in a safe operating condition. LSC 19.5.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, 1999 Edition, Article 370-28(c) requires all junction boxes shall be provided with covers compatible with the box. This deficient practice was not in a patient care area but could affect facility staff.

Findings include:

Based on observation with the Supervisor of General Services on 12/8/15 at 12:34 p.m., there was exposed wiring in a junction box without a cover by the West Exit above the ceiling tile. Based on interview at the time of observation, the Supervisor of General Services acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 1 "Regional Mental Health Center" fire barriers to a nonconforming occupancy was protected by a two hour fire rating. LSC 19.1.2.1 states sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours.
This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on observation with the Supervisor of General Services on 12/8/15 at 12:24 a.m., the wall which separates the "Regional Mental Health Center" on the second floor and the business offices on the second floor, a nonconforming occupancy, did not have any rating tags on either exit doors which open to the business offices. Based on interview at the time of observation, the Supervisor of General Services acknowledged the doors did not indicate an hourly rating tag and confirmed no cite plans were available for review for the construction of the walls.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier wall was protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on observations with the Supervisor of General Services on 12/8/15 at 12:34 p.m., the smoke barrier wall near the West Exit had two unsealed penetrations. Above the ceiling tile was the unsealed penetration which was a one eighth of an inch. Also, above the ceiling tiles was an unsealed penetration around sprinkler pipe measuring one eighth of an inch. Based on interview at the time of observation, the Supervisor of General Services acknowledged the aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 soiled linen storage room, a hazardous area, was provided with self closer and would latch into the frame. This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on observation with the Supervisor of General Services on 12/8/15 at 12:22 p.m., the corridor door to the only soiled linen storage room contained one very large container without a lid. Inside the container was a bag of soiled linen. Based on interview at the time of observation, the Supervisor of General Services could not provide an estimation of how many gallons the very large container could hold, but confirmed the very large container could store more than 32 gallons and confirmed this room was used for soiled linen storage.

Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 3 exits was readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect all staff, visitors, and patients.
Findings include:
Based on observation with the Supervisor of General Services on 12/8/15 at 11:47 a.m., the "Exit To Deck" door had an exit sign above it. Continuing through the discharge was a patio which led to a door, which led down a few stairs without a ramp, then to grass to the parking lot. Based on interview at the time of observation, the Supervisor of General Services acknowledged the aforementioned condition and confirmed that path was considered an exit.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift for 2 of the last 4 calendar quarters. This deficient practice could affect all staff and patients.
Findings include:
Based on record review with the Supervisor of General Services of the fire drill reports titled "Fire Drill Report Form" on 12/8/15 at 10:21 a.m., the documentation for a second shift fire drill for the third and fourth quarter of 2015 and a third shift fire drill for the fourth quarter of 2015 was not available for review. Based on interview at the time of record review, the Supervisor of General Services acknowledged the lack of documentation.

Based on record review and interview, the facility failed to ensure 32 of 32 smoke detectors were maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. This deficient practice could affect all staff, patients, and visitors.

Findings include:

Based on record review with the Supervisor of General Services on 12/8/15 at 10:21 a.m., a smoke detector sensitivity test was not available for review. Based on an interview with Supervisor of General Services at the time of record review, no other documentation was available for review.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic sprinkler piping systems was inspected every five years as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. Section 10-2.2, Obstruction Prevention, states systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on review of sprinkler system documentation with the Supervisor of General Services on 12/8/15 at 10:20 a.m., none of the quarterly sprinkler system inspection and testing records indicated an internal inspection of the sprinkler system pipes had been conducted. Based on interview at the time of record review, the Supervisor of General Services acknowledged the aforementioned condition.


2. Based on observation and interview, the facility failed to replace 4 of 6 bathroom corroded sprinkler heads in 6 bathrooms and 2 of 2 painted recessed sprinkler head covers in room E206. LSC 33.2.3.5.2 refers to LSC section 9.7. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1998 edition, 2-2.1.1 requires any sprinkler shall be replaced which is painted, corroded, damaged, loaded, or in the improper orientation. This deficient practice could affect staff and up to 5 patients.

Findings include:

Based on observation with the Supervisor of General Services on 12/8/15 between 11:55 a.m. and 12:01 p.m., the Supervisor of General Services confirmed four out of six bathrooms had one corroded sprinkler head in each. Also, the Soothing Room E206 contained two recessed sprinkler heads covers. Both recessed sprinkler head covers were painted. Based on interview at the time of observation, the Supervisor of General Services acknowledged the aforementioned conditions.

1. Based on observation and interview, the facility failed to ensure 1 of 1 generator was in accordance with NFPA 110, The Standard for Emergency and Standby Power Systems, Section 6-4.2.2 requires Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. This deficient practice could affect all staff, patients, and visitors.

Findings include:

Based on record review with the Supervisor of General Services on 12/8/15 at 9:42 a.m., the monthly generator forms failed to include the generator load percentage. Based on interview at the time of record review, the Supervisor of General Services acknowledged the aforementioned condition and confirmed that documentation for an annual load bank test was not available for review.


2. Based on record review and interview, the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test. LSC 19.2.9.1 refers to LSC 7.9 which refers to LSC 7.9.2.3 which requires generators to be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems,1999 Edition. NFPA 110, 4-2.4.8 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on review of the facility's Emergency Generator monthly testing log with the Supervisor of General Services on 12/8/15 at 9:42 a.m., the generator log form failed to document the generator cool down time following its load test. During interview at the time of record review, the Supervisor of General Services acknowledged the aforementioned condition and said the generator "runs for 25 minutes with a 5 minute cool down".

Based on observation and interview, the facility failed to ensure 1 of 1 electrical junction boxes observed was maintained in a safe operating condition. LSC 19.5.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, 1999 Edition, Article 370-28(c) requires all junction boxes shall be provided with covers compatible with the box. This deficient practice was not in a patient care area but could affect facility staff.

Findings include:

Based on observation with the Supervisor of General Services on 12/8/15 at 12:34 p.m., there was exposed wiring in a junction box without a cover by the West Exit above the ceiling tile. Based on interview at the time of observation, the Supervisor of General Services acknowledged the aforementioned condition.