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Based on document review, personnel interview, and observation, the surveyor finds the facility failed to provide a building with the required construction type. This deficient practice may, during a fire emergency, affect all patients, staff and visitors from floor to floor and barrier to barrier in order to gain safe access to an adjacent compartment.

Findings include:

On March 8 and 9, 2016, with the RBE and SO present, in multiple Units and at various times throughout this survey, the surveyor observed that all Units and breezeway/ corridors and regular corridors are Type II (000) construction, as defined by NFPA 220.

On March 9, 2016, at 9:50 am, during document review and interview with the BE and SO, the surveyors determined the provider has no information other than all buildings are unprotected noncombustible Type II (000) construction. Based on observation and interview with the BE, the surveyors finds that only about fifty percent of the breezeway/corridors are installed with automatic sprinkler system. Further only about 80% of the E, F, G and H Units are installed with automatic sprinkler system. Unsprinklered, Type II (000) construction does not comply with 19.1.6.2 of NFPA 101 - 2000 Edition.

Based on observation, the surveyor finds exit enclosures and shaft enclosures are not maintained in a fire rated/smoke tight condition. This condition could allow fire to spread vertically and horizontally into patient areas.

Findings Include:

1. On March 8, 2016, at 1:39 pm, with the CE present, the surveyor observed an exit stair door next to Room H016 with a painted U L Label. The fire rating for the door could not be determined in accordance with NFPA 80.

2. On March 8, 2016, at 10:10 am, with the BE and RBE present, the surveyor observed an exit stair door next to elevators in the basement with a painted U L Label. The fire rating for the door could not be determined in accordance with NFPA 80.

Based on observation, the surveyor finds the fire rated doors are not self closing and are not installed to prevent fire from spreading beyond the protected opening. This will allow fire to spread quickly beyond the room of fire origin.

Finding includes:

On March 9, 2016, at 1:20 pm, with the CE present, the surveyor observed a large storage room in the basement of H Unit next to the the loading dock. This space had large rolling fire shutter installed with a fusible link only. Smoke detection on both sides of the shutter, or other equivalent means were not provided in accordance with 19.2.2.2.6 and/or 7.2.1.8.

Based on observation facility failed to install directional EXIT signs. This deficiency could affect all patients, undeterminable number of staff and visitors if the exits cannot be located.

Findings include:

On 03/08/16 at 11:15 am, while accompanied by the SO and CE, the surveyors observed that a directional EXIT sign was not installed in the breezeway/corridor south of F Unit at the A Unit, not complying with 19.2.10.1 and 7.10.

Similar deficiencies were also observed at the following locations:

(a) 03/08/16 at 11:50 am, East exit breezeway/corridor from B Unit
(b) 03/08/16 at 1:30 pm, West exit breezeway/corridor towards C Unit
(c) 03/09/16 at 3:10 pm, South exit breezeway/corridor from D Unit
(d) 03/10/16 at 10:30 am, South exit breezeway/corridor south of J Unit

Based on observations the facility failed to maintain required smoke barriers. This deficiency could affect all patients in occupied Units as well as an indeterminable number of visitors and staff, if the smoke travels from one smoke compartment to another.

Finding include:

On 03/08/16 at 11:05 am, while accompanied by the SO and CE, the surveyor observed the smoke barriers in A Unit, between the North and South wings, were observed to have a large hole/void in the Office A-38 and unprotected steel beam above and the cavity between the metal deck flutes and the steel beam or wall was not fire stopped/smoke sealed for smoke tight with approved fire stop system by Underwriters Laboratories (UL) or other recognized testing agency having one hour for fire rating in accordance with the NFPA 101 Sections 19.3.7.3 and 8.2. The unprotected steel beam also lacks a one hour fire rating as a component of a one hour smoke barrier.

Similar conditions were also observed at the following locations:
(a) On 03/08/16 at 2:05 pm - B Unit
(b) On 03/08/16 at 3:35 pm - C Unit
(c) On 03/09/16 at 10:35 pm - D Unit
(d) On 03/10/16 at 10:55 pm - J Unit

A. Based on observation, the surveyor finds the hazardous areas are not properly enclosed and protected. This condition could allow a fire to spread beyond the room of fire origin and compromise patient exit paths affecting patients, staff and visitors.
Findings Include:
1. On March 10, 2016, at 10:00 am with the BE present, the surveyor observed several rooms including Rm K109, are hazardous areas (storage rooms) in the K Unit. They are sprinklered but are not protected with self-closing corridor doors in accordance with 39.3.2 and 8.4 of NFPA 101 -2000.
2. On March 9, 2016, at 2:00 pm with the BE present, the surveyor observed a Basement Level Grease Trap Room. The room had a door to the CD Tunnel, however that door would not close to latch in accordance with 19.3.2.1.
3. On March 9, 2016, at 2:10 pm with the BE present, the surveyor observed a Basement Level Trades Storage Room which was not spinklered. The corridor door to this space is not a 3/4 hour fire rated door assembly in accordance with 19.3.2.1.
5. On March 9, 2016, at 2:12 pm with the BE present, the surveyor observed a Basement Level Bio Hazard Room which was not spinklered. The corridor door to this space is not a 3/4 hour fire rated self closing door assembly in accordance with 19.3.2.1.



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B. Based on observations of hazardous areas, the facility failed to provide automatic closing hardware which closes the door to the latched position. This deficient practice could affect all patients, if the fire/smoke spreads to the exit egress paths or corridors.

Findings include:


On 03/08/16 at 2:40 pm, while accompanied by SO and CE, surveyor observed the A Unit Service, Storage Room Door was deficient. The Storage Room was larger than 50 square feet and has enough combustible material to be deemed hazardous and the door was not installed with an automatic door closer to comply with NFPA 101, Section 19.3.2.1.

A. Based on observation and staff interview, the surveyor finds multiple paths of egress in the H Unit and K Unit are locked by means which are not otherwise permitted. This deficient practice could affect the patients, staff and visitors in the building during a fire emergency.
Findings Include:
1. On March 10, 2016, at 10:50 am, with the BE present, the surveyor observed the K Unit is not a psychiatric area. It has no patient programs and is a Business Occupancy. The surveyor observed multiple locked doors in a required path of egress which required keys to exit. The exit paths do not comply with 7.2.1.6.1 or 7.1.6.2 and or 7.3.2.5. The exception for locked doors under 19.1.1.1.5 are not permitted in this building.
2. On March 10, 2016, at 10:30 am, with the BE present, the surveyor observed the K Unit has an entrance vestibule which provides access from a corridor to the two wings in this Unit. This vestibule is a required exit access corridor and lacks an illuminated exit sign at two required, remote exit paths from this space, which are not locked (19.2.10). Only one path is identified.
3. On March 9, 2016, at 11:00 am, with the BE and CE present, the surveyor observed the H Unit has regular psychiatric training and patient treatment. Two 1st floor corridors to the north have exterior doors marked as exits. Each door has a magnetic locking device. On March 10, 2006, at 11:00AM, staff were not able to provide the keys which would unlock these doors. The provider indicated that staff was not carrying the key at all times and no one was able to unlock the doors, under CMS Guidelines and 19.2.2.2.4, exception # 1, these locked doors are not permitted.
4. On March 9, 2016, 10:00 am, with the BE and SO present, the surveyor observed multiple breezeway/corridors, building corridors and the E, F, G, and H Units all define a very large interior courtyard. Based on observation and personnel interview on multiple days with the BE, the surveyor finds there are multiple doors which provide access to this courtyard. Some doors are locked while other allow free access to the courtyard. However, many or these doors do not allow access back into the building without a key. Some doors have no hardware to allow no re-entry. On March 9, 2016, at 10:15 AM the BE indicated that from the courtyard side, no doors are identified to indicate which allows re-entry. Exit paths from this courtyard in accordance with 19.2.10 are not identified



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B. Based on observation, the surveyor finds the facility contains a dead-end corridor. This deficient practice could affect patients as well as an undeterminable number of staff and visitors.
Finding includes:
On 03/10/16 at 10:45 am, while accompanied by SO, CE and RBE, the surveyor observed a dead-end condition, from the junction of breezeway/corridor south of the J Unit and west of K Unit, of 110 ', which does not comply with NFPA 101, 19.2.5.10.

Based on observations, the facility failed to maintain the fire barriers. This deficiency could affect all patients as well as an indeterminable number of visitors and staff, if the fire travel from one compartment to another due to deficient fire barriers.
Findings include:
1. On 03/08/16 at 11:15 am, while accompanied by the SO and CE, the surveyors observed the fire barrier in A Unit (designated fire barrier/separation wall with A label fire door) contained an unprotected steel beam embedded the length of the fire barrier, and the space between the beam and metal deck flutes were not fire stopped with approved fire stop system by Underwriters Laboratories (UL) or other recognized testing agency. The provider lacks UL Assembly # for 1 or 2 hours barriers with an embedded steel beam. This does not comply with 8.2.3.

Locations include:

(a) On 03/08/16 at 1:45 pm - B Unit
(b) On 03/08/16 at 3:40 pm - C Unit
(c) On 03/09/16 at 10:25 pm - D Unit

Based on document review and personnel interview, the surveyors find the facility lacks detailed and specific information about required life safety code systems and barriers in their facility. This condition could delay evacuation in an emergency.

Findings Include:

1. On March 9, 2016, with the BE, RBE, and SO present during a comprehensive document review of all life safety systems, the surveyors determined the provider has little to no information which clearly identifies required life safety systems, including but not limited to:

Location of two hour fire barriers and U L Numbers for two hour assemblies.
Locations of one hour smoke barriers
Location of all unsprinklered rooms, areas or corridors
The location of any required Horizontal Exits
The location and fire rating for vertical shaft enclosures
Location of all hazardous areas.
Identification of all required exit access corridors
Location and fire ratings for exit stair enclosures.


1. On March 8, 2016, at 10:00 am, with the BE present, the surveyor observed the posted evacuation plans are confusing and not correctly oriented to the viewer.

Locations include but are not limited to:

a. On March 8, 2016 at 12:00 pm, A Unit, with the CE present, at nurses station

b. On March 9, 2016 at 1:10 pm, H Unit, with the CE present, small Lobby east of administration

A. Based on observation and testing of the fire alarm system and interview, the surveyors find the facility's fire alarm system is not installed and maintained. Failure to maintain this life safety system cause malfunction during a fire emergency affecting all patients, staff and visitors in the building.
Findings Include
1. On March 8, at 11:00 am, with the BE present, the surveyor observed that no fire alarm pull station is provided within five feet of the Main Lobby entrance/exit in accordance with NFPA 72.
2. On March 9, 2016 at 11:30 am, with the BE and CE present, the surveyor observed the fire alarm panel in J Unit had a trouble condition illuminated on the panel. The provider was not able to identify what this trouble condition was and/or how long it had been in trouble.
3. On March 9, 2016, at 1:50 pm, with the CE, BE, SA and security personnel, the surveyor observed the trouble condition in J Unit prevents the transmission of alarm, supervisory and trouble conditions to the Main Fire Alarm Annunciator panel located in the Security Office of the H Unit, in a accordance with NFPA 72 - 2000.
4. On March 9, 2016 throughout this survey, with the BE and CE present, the surveyors observed that the fire alarm Annunciator panel for each of seven Units is located in a locked room and not at a constantly attended location in accordance with NFPA 72.
5. On March 10, 2016, at 1:55PM, with the BE, CE, RBE and SO and security personnel, the surveyor observed the alarm, supervisory and trouble conditions were transmitted to the main fire alarm annunciator panel both with audible and visual notification. However that audible notification could not be heard 20 ' away at the main security counter and the office is not constantly attended. This condition does not comply with NFPA 72-1999.





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B. Based on observation, the fire alarm panels are not properly labeled and maintained. This could affect facility maintenance staff if power is lost to the system and maintenance is required to panels.

Findings include:

On 3/9/16 at 9:30 am, while accompanied by the BE, the surveyor observed the fire alarm panels located in each of the patient living areas were not labeled with the life safety panel and circuit serving them in accordance with the 1999 Edition of NFPA-72, Section 1-5.2.5.2.

On 3/9/16 at 9:35 am, while accompanied by the BE, the surveyor observed the fire alarm panels were located in unoccupied areas and were not protected by a smoke detector in accordance with NFPA-72, Section 1-5.6.

Based on the record review and staff interview, the surveyors finds that the facility failed to properly install and maintain the fire alarm system. This deficient practice could affect all patients in all patients Units Smoke Zones, as well as an undeterminable number of staff and visitors.

Finding includes:

On 03/09/16 at 11:15 am, during document review and interviews with the SO and CE, the surveyors determined the facility failed to conduct smoke detectors Sensitivity Test in the past two years and lacked record of individual testing of each device in accordance with NFPA 70 and NFPA 72.

A. Based on observation, personnel interview and document review, the surveyor finds the sprinkler systems are not installed and maintained. Failure to maintain the sprinkler systems could cause a malfunction during a fire event and could affect all patients, staff, and visitors within the specific fire compartment.

Findings include:

1. On March 9, 2016, at 2:10 pm, with the BE present, the surveyor observed the H Unit penthouse had a separate sprinkler zone with a control valve and a flow switch. However, no inspectors test valve was found installed in accordance with NFPA 13.

2. On March 9, 2016, at 9:30 am, with the BE, RBE and SO present, during document review of quarterly sprinkler testing and maintenance for the previous 12 months and interview, the surveyor finds there is no record of quarterly testing of the flow switches for 7 of 7, inspectors test valves in the penthouses for each Unit.

2. On March 8, 2016, at 10:30 am, with the CE, BE and SO present, the surveyors observed that A Unit had drain outlets for two inspector's test valves. The surveyors noted that these outlets were not designed to simulate the flow of one sprinkler head. Upon further inspection, the surveyors determined the actual inspector's test valves did not appear to be designed to simulate the flow of one sprinkler head. The surveyors observed the same condition for two or three sprinkler valves at each seven of seven Units.

3. On March 9, 2016, at 2:30 pm with the CE present, the surveyor observed a vehicle garage in the Basement of the H Unit. This garage was protected with automatic sprinkler system, however, the sprinkler heads would be blocked when the overhead door is open. The sprinkler heads are not installed to comply with NFPA 13, without obstruction.

4. On March 9, 2016, at 1:30 pm, with the CE present, the surveyor observed in the H Unit corridor, the ceiling tiles in the corridor were missing in front of Room H37 and H39, compromising the sprinkler protection. This condition does not comply with NFPA 13.

5. On March 8, 2016, at 10:10 am with the BE, CE and SO present, the surveyor observed a vending machines area in the corridor of the H Unit. The vending machines area had a decorative header which obstructed the sprinkler head in this area. This condition was observed and not observed and abated during the annual sprinkler inspection, testing and maintenance and does not comply with NFPA 13.



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B. Based on the record review and staff interview, the surveyor finds the facility failed to properly maintain the automatic sprinkler system. This deficient practice could affect all patients in all patients Units Smoke Zones, as well as an indeterminable number of staff and visitors.

Findings include:

1. On 03/08/16 at 11:50 am, sprinkler system Inspector Test Drain Orifice was not the same size orifice as the installed sprinkler heads in accordance with NFPA 13.

2. On 03/08/16 at 2:40 pm, it was observed in the B Unit North back office hallway open closet was filled with clean laundry in the plastic bags up to the ceiling blocking the sprinkler head, which does not comply with the NFPA 13.

3. FIRE PUMP: Annual inspection report of the sprinkler system fire pump conducted on 11/04/15 by ' Rogers Pump Sales & Service ' had the following comments, not in compliance with the NFPA 25.
" Gauges on fire pump and system pipes do not read correct pressure, need to be replaced " . Surveyors found no record of correction.
4. The SO indicated that annual inspection report of the sprinkler system was not available for review.
5. 5 year calibrations documentation of the water flow pressure gauges were not available for review. NFPA 25.

Based on observation and staff interview, the surveyor finds the fire extinguishers are not installed and maintained. This condition could prevent proper use of an extinguisher in an emergency.
Findings include:
On March 10, 2016 at 10:10 am with the BE and CE present, the surveyor observed a fire extinguisher placed on the floor of the K Unit South Penthouse near the floor access ladder. The surveyor noted and the BE agreed that the same condition exist in every penthouse in every Unit and the fire extinguishers were not properly mounted in accordance with NFPA 10

A. Based on observation, the surveyor finds the ducted HVAC systems are not installed with compliant fire dampers at duct penetrations. This condition could allow the spread of fire and smoke in ductwork, beyond all fire or smoke barriers and quickly affect all patient areas.
Findings include:
1. On March 9, 2016 at 2:30 pm, with the BE present, the surveyor observed a concrete block shaft enclosures with multiple ducts inside, between the 1st Floor Male and Female Housekeeping / Locker Rooms. The fire rating of this shaft was not known. A stainless steel duct penetrates the shaft in the Female locker Room from an abandoned dishwasher exhaust but lacks a fire damper at the floor penetration in accordance with 3-3.4.4 of NFPA 90A-1999. Additionally an insulated duct from above in the same room penetrates the penthouse floor without a fire damper in accordance with 3-3.4.4 of NFPA 90A-1999.


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B. Based on the record review and staff interview, the surveyors determined that the facility failed to inspect 6 years testing/maintenance and inspection of the fire dampers. This deficient practice could affect all patients in all patients Units, as well as an indeterminable number of staff and visitors.

Finding includes:

On 03/09/16 at 11:45 AM, during document review and interviews with SO and CE, the surveyors determined the facility has failed to conduct and document 6 year inspection, testing and maintenance of the fire and smoke dampers, as required by 19.5.2.1, 9.2 and NFPA 90A. The provider had a one page document that did not include any device by unique ID# and by location.

Based on observation, the surveyor finds the cooking areas, kitchen exhaust hood, kitchen grease ducts and kitchen exhaust fans are not installed and maintained in accordance with National Standards. This condition could allow fire and smoke to spread out from the kitchen exhaust duct and affect all patients, staff and an undeterminable number of visitors.


Findings include:
1. On March 9, 2016 at 1:30 pm, with the BE and RBE present, the surveyor observed a patient training kitchen in the 1st Floor of the H Unit with a residential electric range. This range is in the health care building.

The provider lacked the following for a training program:
a. The room had an ABC fire extinguisher instead of a BC or Type K extinguisher in accordance with NFPA 10.
b. The provider lacked a written procedure which identifies the use of this range for patient training and rehabilitation only. The provider lacks a written narrative which indicates how the above range will be controlled and maintained.

2. On March 9, 2016 at 2:45 pm, with the BE present, the surveyor observed the provider has a main kitchen in the Basement of the H Unit. The kitchen has a cooking line with a Type I kitchen hood and suppression above four fryers. This area is deficient and does not comply with NFPA 17A:
a. Two of four fryers have been moved away from the suppression nozzles above.
b. The kitchen exhaust duct in the Basement is wrapped in drywall above the ceiling. The provider was not able to demonstrate how access panels for cleaning are provided in accordance with NFPA 96.
c. The kitchen exhaust duct rises up from the Basement, through a rated shaft enclosure at the 1st Floor and penetrates two levels or a mechanical penthouse above. The kitchen exhaust duct shares same vertical shaft with multiple environmental (supply, return or exhaust) ducted systems. The kitchen exhaust fan is located in the same penthouse space as supply air HVAC units, exhaust fans and other HVAC systems with no fire separation. The kitchen exhaust duct and fan are not separated from all other HVAC systems by a separate fire rated shaft enclosures and fire separation in the Penthouse in accordance with NFPA 90A - 1999, Section 3-343.

Based on observation, the surveyor finds that the access doors to a trash chute/compactor are not installed correctly. This condition could allow the spread of fire and smoke from the trash compactor to patient areas affecting patients, staff and an undeterminable number of visitors.
Findings include:
1. On March 9, 2016 at 2:35 pm, with the BE and RBE present, the surveyor observed a 1st Floor main Corridor and Basement Corridor of the H Unit, has a 90 minute rated trash chute door with a trash compactor below. The door on both levels lacked self closing hardware in accordance with NFPA 82.

Based on observation, the facility failed to maintain a proper emergency power system. If the generator fails to operate upon the loss of normal power, this could affect all occupants of the building.

Findings Include:

A. On 3/9/16 at 11:00 am, while accompanied by the BE, the surveyor observed the emergency generator annunciator is not located at a 24 hour staffed location in accordance with the 1999 addition of NFPA-110, Section 3-5.6.1.

B. On 3/9/16 at 11:05 am, while accompanied by the BE, the surveyor observed the emergency generator is not equipped with a remote stop switch in accordance with the 1999 Edition of NFPA-110, Section 3-5.5.6.

Due to the number, variety, and severity of the life safety code deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures (ILSM) until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the ILSM to remain in place as work towards the completion of its PoC progresses.

Based on observation, the emergency power was not properly divided into three branches. This could affect all occupants of the building if the emergency power failed to operate properly upon loss of normal power.

Findings include:

On 3/9/16 at 10:45 am, while accompanied by the BE, the surveyor observed the transfer switches serving emergency panels were labeled for area served and not for the branch of emergency power served, and the panels in each area were serving mixed emergency loads. This is not in compliance with the 1999 Edition of NFPA-70, Sections 517-30 through 517-35.

Base on observation, the surveyors find the electrical systems and materials are not installed and maintained. This condition could cause a fire and/or delay in a response in an emergency.

Findings include:

1. On March 9, 2016, at 10:30 am, with RBE present, the surveyor observed a Basement foyer with two large electrical panels recessed into the wall. Access to these panels was blocked by three large waste containers. Three feet of clear space in front of each panel was not maintained in accordance with NFPA 70.

2. On March 9, 2016, at 1:50 pm, with security personnel present, the surveyor observed multiple plug strip plugged in, in series. One plug strip into another to provide extended power is not permitted in NFPA 70.