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Based on observation and staff interview during tour of building #1, it was determined the facility failed to ensure the two hour fire wall was constructed to meet the National Fire Protection Association (NFPA) requirements of chapter 8.2.1.3. This had the potential to affect all patients utilizing this area of the facility. The patient census was 34.

Findings include:

From within the activity room of unit 56, observation was made of a 90 minute fire rated double door leading into the drug and alcohol rehab unit which lacked latching hardware and prevented the doors from engaging properly when closed. Approximately 20 feet to the right of this door, another double door was observed to be fire rated for 90 minutes. This door separated the hospital from building 61 and was observed to have a small circular hole in the left top door leaf.
Additionally, observation was made of an approximate eight by sixteen inch opening in the north two hour fire rated barrier between the single leaf door and the double leaf door separating units 52 and 53.

These findings were confirmed by staff AA and BB during tour.

Based on observation during tour and staff interview it was determined the facility failed to ensure all exit discharge doors in the drug and alcohol unit 56 were unlocked in the event of an emergency. Additionally, based on observation and staff interview the facility failed to ensure exit doors were equipped with locks which could open with only one motion in accordance with NFPA 101-2012 Edition, Section 7.2.1.5.10.2. This had the potential to affect all patients utilizing these areas of the facility. The patient census for unit 56 was eight and the staff census for the kitchen area was 13.

Findings include:

During tour of the drug and alcohol unit 56 on 2/1/18 with staff AA, observation was made of an alarmed exit discharge door next to room 127 which failed to open due to being locked. Staff AA stated this door is never supposed to be locked and questioned the units staff members regarding who locked the door. Three separate staff personnel attempted to use their key to unlock the door before the lock was disengaged. Once the door was unlocked, it was able to open freely.

Observation on 01/30/18 during tour of the facility between 10:30 A.M. and 4:00 P.M. noted egress locks located on the exit doors installed throughout the facility. Further examination inside the kitchen discovered the egress doors were equipped with dual action locks. Two surface mount slide bolt action locks were installed at the top of the door of both leaves and underneath the panic hardware.

Interview with Staff AA and Staff BB verified the findings at the time of discovery.

Based on observation during facility tour and staff interview it was determined the facility failed to ensure all exit discharges provided all occupants a safe access to a public way according to NFPA 101 2012 edition, chapter 7.7. This had the potential to affect all patients utilizing these areas of the facility. The patient census was 34.

Findings include:

During facility tour with staff AA and BB on 1/30/18 observation was made of three exit discharges from unit 53 (NW, NE and SE corners) and two exit discharges from unit 52 (NE and SE corners) which failed to provide a level walking surface to a paved common way. All of the exits discharged to a cement stoop surrounded by a large grassy area and due to the sod and large embankment surrounding the east side of the discharge exits, it would not be conducive for patients who may be using assistive devices or who may have other ambulatory issues. The distance from each exit discharge was measured to a public way and was determined to range from 12 feet to 175 feet.

This finding was observed by both staff AA and BB during tour.

Based on facility tour and staff interview it was determined the facility failed to ensure all equipment locations were equipped with battery powered emergency lighting according to NFPA 101, 2012 edition, chapter 7.3.1. This had the potential to affect all patients utilizing this facility. The patient census was 34.

Findings include:

Facility tour took place on 1/31/18 with staff AA. During tour of room 208 where the generator transfer switch is located, observation was made that the room lacked emergency lighting. This was shared with staff AA during tour.

Based on facility tour, review of evacuation plans and staff interview it was determined the facility failed to ensure all exit accesses and discharges were equipped with exit signage according to NFPA 101, 2012 edition, chapter 19.2.10 and 7.10.1.2.1. This had the potential to affect all patients utilizing this facility. The patient census was 34.

Findings include:

During tour of unit 53 exit discharge located at the SE corner which opened into an enclosed courtyard, observation was made of secured double doors located in the enclosure which lacked an exit sign. Additionally, tour of the kitchen in unit 56 revealed the designated exit lacked an exit sign above the double doors leading directly to the exit pathway corridor.

During review of the facility's emergency egress evacuation plan, it stated the exit is a designated egress for the kitchen staff.

These findings were verified by both staff AA and BB during tour of these areas.

Based on review of the fire alarm testing documentation and staff interview it was determined the facility failed to ensure all smoke detectors were sensitivity tested according to NFPA 72 2010 edition 14.4.5.3.2. Additionally, based on record review, interview and observation the facility failed to maintain the fixed temperature, non-restorable heat detectors in accordance with NFPA 72-2010 Edition, Section 14.6.2.2 and Table 14.4.2.2. This had the potential to affect all patients within the facility. The patient census was 34.

Findings include:

The fire alarm system documentation review was reviewed on 1/29/18. The documentation lacked any evidence that a sensitivity test was performed on all the smoke detectors.

This was confirmed by staff CC during interview on 1/31/18 at approximately 1:45 PM when staff CC stated they have no record of any sensitivity testing of the smoke detectors.


Observations on 01/30/18 between 10:30 A.M. and 4:00 P.M., during tour of the facility noted the application of heat detectors installed throughout the facility. Examples include but not limited to: Main Lobby, Conference Room, Building 51 and Building 52 and Pump Room.

During record review of the fire alarm inspection report dated 01/08/18 there was no record of the fixed type non- restorable type heat detectors were tested every five years. No supporting documentation was provided on site to indicate the heat detectors were tested.

Interview with Staff AA and Staff BB verified the findings at the time of discovery.

Based on review of the fire alarm testing documentation and staff verification it was determined the facility failed to ensure all smoke detectors were sensitivity tested according to NFPA 72 2010 edition 14.4.5.3.2. This had the potential to affect all patients within the facility. The patient census was 34.

Findings include:

The fire alarm system documentation review was reviewed on 1/29/18. The documentation lacked any evidence that a sensitivity test was performed on all the smoke detectors.

This was confirmed by staff CC during interview on 1/31/18 at approximately 1:45 PM when staff CC stated they have no record of any sensitivity testing of the smoke detectors.

Based on review of the sprinkler testing documentation and staff interview it was determined the facility failed to ensure all components of the sprinkler system were tested/inspected according to NFPA 101 2012 edition. This had the potential to affect all patients within the facility. The patient census was 34.

Findings include:

The sprinkler system documentation review was reviewed on 01/29/18. The documentation lacked evidence of a 5 year internal pipe inspection.

Staff CC verified on 1/31/18 at 1:41 PM they have not performed this function and have scheduled to have it completed next week.

Based on review of the sprinkler testing documentation and staff verification it was determined the facility failed to ensure all components of the sprinkler system were tested/inspected according to NFPA 101 2012 edition. This had the potential to affect all patients within the facility. The patient census was 34.

Findings include:

The sprinkler system documentation review was reviewed on 1/29/18. The documentation lacked evidence of a 5 year internal pipe inspection.

Staff CC confirmed on 1/31/18 at 1:41 PM they have not performed this function and have scheduled to have it completed next week.

Based on observation during facility tour and staff interview it was determined the facility failed to ensure all corridor doors closed properly to resist the passage of smoke according to NFPA 101 chapter 19.3.6.3. This had the potential to affect all patients utilizing this area of the facility. The patient census was 34.

Findings include:

Facility tour of unit 52 took place on 1/30/18 with staff AA and BB. During tour several patient room doors were checked for the resistance of smoke. Patient room doors 603, 606, 608, 609, 610, 611, 614, 630, 631, and 632 failed to close into the door frame leaving a substantial gap between the door and the door frame.

This finding was verified by both staff AA and BB during tour.

Based on observations and staff interview the facility failed to provide smoke barriers to resist the passage of smoke in accordance with NFPA 101-2012 Edition, Section 8.5.6.2. This had the potential to affect all patients in the facility. The patient census was 34.

Findings include:

Observations were made during a facility tour on 01/30/18 with staff AA and BB of penetrations in the smoke barriers throughout the facility. Further examination of the above suspended ceiling space revealed the following penetrations:

1. Building 52- near Room #441 above the Activity Room Entrance Door discovered a two inch penetration around the metal ceiling joist.
2. Building 52- near Room #443 outside the Activity Room hall discovered a three inch diameter section of missing drywall around the angular space of low voltage communication wire.
3. Building 52 near Room #434 discovered a four-inch square section of missing drywall around the angular space of the heating and cooling duct work. Additionally, two sections of missing drywall were missing around the angular space of electrical conduit, which measured two inches in diameter. Also, a three inch section of drywall missing around the angular space of electrical conduit.
4. Building 53 near Room #504 discovered two sections of missing drywall, which measured two inches in diameter around the angular space of electrical wire.
5. Building 53 near Room #525 above the cross corridor doors discovered a two inch section of missing drywall around the angular space of low voltage communication wire.
6. Building 53 near the Nurses Station near Room #560 discovered two sections of missing drywall, which measured eight inches and 12 inches.
7. Building 51 near Room #714 discovered a four inch section of missing drywall creating an open void in the smoke barrier.
8. Building 51 near the Nurses Station by Room #738 discovered three penetrations of missing drywall around the angular space of low voltage communication.

Interview with Maintenance Director #1 verified the findings at the time of discovery.

Based on observation during facility tour and staff verification it was determined the facility failed to ensure all smoke barrier doors closed properly and gaps between the doors were less than 1/8th inch according to NFPA 101 2012 edition. This finding had the potential to affect all patients in the facility. The patient census was 34.

Findings include:

Facility tour took place on 1/30/18 with staff AA and BB. During tour of the smoke barriers observation was made of doors having gaps greater that 1/8 inch between the door-leafs when in the closed position and doors that failed to close properly to resist the passage of smoke in the following locations:

Ground Floor Unit 56
1) Double doors adjacent to room 231 had a gap between the door leafs.
2) Double doors between rooms 220 and 225 had a gap greater than 1/8th inch.

Office and Front Lobby Area
3) Double smoke barrier doors located between rooms 443 and 442 failed to close properly.
4) Double smoke barrier doors adjacent to room 446 failed to close properly.
5) Right leaf (facing the doors outside unit 55) of the double doors in the two hour fire barrier which lead into unit 55 and adjacent to the NW stairs was observed to not open properly.

These findings were verified by both staff AA and BB during tour on 1/30/18.

Based on fire drill documentation review and staff interview it was determined the facility failed to ensure all fire drill transmission times for fire drills performed before 9:00 PM and after 6:00 AM were documented according to NFPA 101 19.7.1. This had the potential to affect all patients utilizing the facility. The patient census was 34.

Findings include:

Fire drill documentation review took place on 1/29/18. No documentation was found in order to verify the transmission times of the signal sent from the activated pull station device to the offsite monitoring company for the fire drills performed before 9:00 PM and after 6:00 AM.

This finding was verified by staff CC during interview on 1/31/18 at approximately 2:30 PM.

Based on fire drill documentation review and staff verification it was determined the facility failed to ensure all fire drill transmission times for fire drills performed before 9:00 PM and after 6:00 AM were documented according to NFPA 101 19.7.1. This had the potential to affect all patients utilizing the facility. The patient census was 34.

Findings include:

Fire drill documentation review took place on 1/29/18. No documentation was found in order to verify the time of the fire drill or the transmission times of the signal sent from the activated pull station device to the offsite monitoring company for the fire drills performed before 9:00 PM and after 6:00 AM.

This finding was verified by staff CC during interview on 1/31/18 at approximately 2:30 PM.

Based on observation and interview the facility failed to maintain the smoking area in accordance with NFPA 101-2012 Edition, Section 19.7.4. This had potential to affect all patients who reside in the facility. The patient census was 34.

Findings include:

Observations during tour of the facility on 1/30/18 with staff AA and BB revealed numerous cigarette butts discarded on the combustible wooden landscape mulch, sidewalk and adjoining parking lot located outside the exit discharge of the main entrance. Additionally, numerous discarded cigarettes were outside the ground floor activity room courtyard near the Building 56 entrance, building 52 interior courtyard first level and ground, building unit 53 interior courtyard first level and ground level and outside of building entrance 435.

Interview with Staff AA on 02/01/18 at 3:00 P.M. revealed these locations were not the designated smoke locations for staff or patients. Self-closing metal containers were not provided to discard cigarette butts.

Observations of building 52 courtyard first level and ground level discovered numerous cigarettes butts discarded laying on the concrete ground mixed with combustible dried leaves located inside the enclosed courtyard. Interview with Staff AA on 02/01/18 at 3:30 P.M. revealed Building 52 first floor courtyard was the approved staff member smoking location. Self- closing metal containers were not provided to discard cigarette butts.

Interview with Staff AA and Staff BB verified the findings at the time of discovery.

Based on generator documentation review and staff interview it was determined the facility failed to ensure all generator transfer load times were documented according to NFPA 99 6.6.4.1.1.1. This had the potential to affect all patients utilizing the facility. The patient census was 34.

Findings include:

Generator documentation review took place on 1/29/18. No documentation was found in order to verify the transfer time of the generator load to be no greater than ten seconds after starting the generator.

This finding was verified by staff CC during interview on 1/31/18 at approximately 2:30 PM when staff CC stated they have not been documenting those times.

Based on generator documentation review and staff verification it was determined the facility failed to ensure all generator transfer load times were documented according to NFPA 99 6.6.4.1.1.1. This had the potential to affect all patients utilizing the facility. The patient census was 34.

Findings include:

Generator documentation review took place on 1/29/18. No documentation was found in order to verify the transfer time of the generator load to be no greater than ten seconds after starting the generator.

This finding was verified by staff CC during interview on 1/31/18 at approximately 2:30 PM when staff CC stated they have not been documenting those times.

Based on observations and staff interview, the facility failed to provide electrical wiring in accordance with the requirements of NFPA 99-2012 Edition, Section 10.2.3.6. This finding could affect all 34 patients.

Findings include:

Observations on 01/30/18 during tour of the facility between 10:30 A.M. and 4:00 P.M., noted the application of an electrical extension cord used for permanent wiring inside the Kitchen Dry Storage Room installed through the suspended ceiling. Further examination and interview with Kitchen Manager #1 revealed the extension cord was found plugged into an air conditioner inside the kitchen manager's office.

Interview with Staff AA and Staff BB confirmed this finding at time of discovery.