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Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice had the potential to affect 15 of 15 residents. There are 3 of 5 cross corridor dorrs and 2 of 7 Exit discharge door are deficient.

Findings:

During the facility tour and interview with staff, between the hours of 8:00 am to 6:00 pm on 8/31/2017 it was observed the Psychiatric unit wing located in the northeastern most area of the Hospital magnaetic locks for the interior cross corridor doors and the Exit double doors fail to realease when the electric power is lost and the generator is operating on full load.

Interview with Administrator revealed the facility was not aware that the psychiatric interior cross corridor doors and the exit discharge doors did not properly remain unsecured when the generator was activated.

Based on visual observation the facility failed to assure that the fire alarm system was annually inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 15 of 15 residents.

Findings:

During the facility tour, between the hours of 8:00 am to 6:00 pm on 8/31/2017 it was observed the main fire alarm system was last annually inspected by Fire Quest on 3/24/2016.

Interview with the Administrator revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system.

Based on visual observation the facility failed to provide sensitivity testing on the building smoke detectors that are connected to the fire alarm system. The detectors offer a means of activating the fire alarm system to provide emergency notification to the occupants of the building. This deficiency has the potential to affect 15 of 15 residents.

Findings:

During the facility tour, between the hours of 8:00 am to 6:00 pm on 8/31/2017 it was observed the front entrance waiting area and the western most corridor of the front entrance waiting area is missing properly spaced smoke detection.

Interview with the Administrator revealed the facility was not aware that the sensitivity testing of the smoke detectors is delinquent. During the exit interview this was also acknowledged by the Administrator..

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 15 of 15 residents.

Findings:

During the facility tour, between the hours of 8:00 am to 6:00 pm on 8/31/2017 it was observed the maintenance building located in the rear of the campus is lacking a vertical wall room enclosure for one of the two laundry rooms and the hot water heater room. The suspended ceiling tile is missing in the other laundry room and is mssing in the front entrance laundry room vestibule. These constrction features allow for proper heat collection for the sprinkler system to actuate as soon as possible.

Interview with Administrator revealed the facility was not aware the automatic sprinkler system walls and suspended ceiling were not complete.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. This deficiency has the potential to affect 15 of 15 residents.

Findings:

During the facility tour, between the hours of 8:00 am to 6:00 pm on 8/31/2017 it was observed the facility failed to document the sprinkler quarterly inspections from a qualified person for the past year.

Interview with the Administrator revealed the facility was not aware that the annual and/or quarterly inspections had not been conducted on the automatic sprinkler system.

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 15 of 15 residents.

3 of 3 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour, between the hours of 8:00 am to 6:00 pm on 8/31/2017 it was observed the medical patient corridors and the pychiatric patient corridor is being used for return air purposes. Thus, HVAC corridor return air is conditioning the patient rooms.

Interview with Administrator revealed the facility was not aware the HVAC system was using the corridors as a return air plenum.

Based on visual observation the facility failed to assure live electrical parts of electrical equipment operating at 50 volts were guarded against accidental contact by approved enclosures. A properly listed UL electrical enclosure is essential life safety equipment for this facility. The deficient practice had the potential to affect all maintenance staff.

Findings:

During the record review, between the hours of 8:00 am to 6:00 pm it was observed the maintenance building located in the rear of the hospital campus has two electrical breaker panels with exposed wires due to lacking a proper U.L. listed electrical enclosure.

Interview with the Administrator revealed the facility was not aware that the electrical equipment was improperly protected to guard against accidental electrocution.