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Based on observation and interview, the facility failed to maintain the required building separation with proper wall construction and functioning self-closers and sequencers on separation doors in accordance with NFPA 101 (2012 edition), 19.1.1.4 and 19.1.3.3. These deficient practices could affect all 59 patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 2/26/18 at 1:50 pm, observation in the B010 corridor revealed the pair of N-010 separation doors between Gordon and Kempster had a faulty sequencer/coordinator and would not close in the proper sequence to provide for positive latching and required separation.
2. On 2/26/18 at 1:51 pm, observation in the B010 corridor adjacent to the N-010 separation doors revealed a separation wall between Gordon and Kempster that had two 9 inch diameter holes in the wall from abandoned chiller lines. Staff C and Staff U stated these lines were abandoned about a year ago.

These deficient practices were confirmed by Staff C and Staff U at the time of discovery.

Based on observation and staff interview, the facility did not ensure that doors with self-closing devices were maintained in accordance with NFPA 101 (2012 edition), 19.2.2.2.7 and 7.2.1.8.2. This deficient practice could affect all of the patients and an undetermined number of staff and visitors.

Findings Include:

On 2/26/18 at 1:35 pm, observation of the double set of fire barrier doors between Lobby B001 and the Tunnel revealed that the self-closing fire-rated door would not properly latch when tested because the coordinator was not properly functioning. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

Based on observation and interview, the facility failed to maintain vertical openings enclosure with fire-stopped floor penetrations in accordance with NFPA 101 (2012 edition), 19.3.1.1 through 19.3.1.6. This deficient practice could affect 36 of the 59 patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 1:55 pm, observation in the basement northeast corridor revealed two 5 inch diameter holes cored in the floor with 3 inch diameter PVC pipe through the concrete floor assembly, with gaps up to 1 inch around the perimeter with no firestopping.

This deficient practices were confirmed by Staff C and Staff U at the time of discovery.

Based on observation and interview, the facility failed to provide doors which resist the passage of smoke, and self-closing and latching doors to provide separation between hazardous areas and other spaces in accordance with NFPA 101 (2012 edition), Section 19.3.21.2, 19.3.2.1.5((7), 8.4.3.5 and 7.2.1.8. These deficient practices could affect 41 of the 59 patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 2/26/18 at 1:24 pm, observation in the basement SL008 mechanical room revealed a hazardous storage room which double doors on the corridor which had no self-closer or positive self-latching hardware on the inactive door leaf. The inactive door leaf had manual flush bolt hardware.
2. On 2/26/18 at 2:04 pm, obsevation in the N-170D laundry closet revealed the double doors had up to a 3/16 inch gap at the leading edge between the door leaves with no astragal to resist the passage of smoke.

These deficient practics were confirmed by Staff C and Staff U at the time of discovery.

Based on observation and staff interview, the facility did not ensure that the 1-hr. fire resistance rated hazardous rooms were maintained in accordance with NFPA 101 (2012 edition), 19.3.2.1 and 19.3.2.1.3. These deficient practices could affect all of the patients and an undetermined number of staff and visitors.

Findings include:

1. On 2/26/18 at 1:32 pm, observation revealed in Storage Room #22 a 3" diameter PVC pipe penetration through the wall. The penetration was not properly fire stopped in accordance with approved materials and methods. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

2. On 2/26/18 at 2:24 pm, observation revealed in Storage Room #100 a 3' x 2' opening in the concrete masonry unit wall. The opening was not properly fire stopped in accordance with approved materials and methods. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

3. On 2/26/18 at 3:39 pm, observation in Linen Room #2128 revealed that a basket was being used to prevent the door from self-closing. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

Based on observation and interview, the facility failed to provide a fire alarm system in accordance with the requirements of NFPA 101 (2012 edition), 19.3.4 and 9.6 and NFPA 72 (2010 edition), 17.7.5.6.5.2. This deficient practice could affect 5 of the 59 patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 1:31 pm, observation in the basement S-005 locksmith shop revealed the hazardous room corridor door was held open with a mag hold-open with no smoke detection on the room side.

This deficient practice was confirmed by Staff C and Staff U at the time of discovery.

Based on record review and interview, the facility failed to provide annual fire alarm system testing and inspection in accordance with the requirements of NFPA 101 (2012 edition), 19.3.4, 9.6, and 9.6.1.3; as well as NFPA 72 (2010 edition), Chapter 14. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 12:09 pm, review of facility fire alarm testing and inspection documents revealed annual testing and inspection exceeded the annual requirement with the most recent testing and inspection performed on 6/10/16.

This deficient practice was confirmed by Staff C at the time of discovery.

Based on record review and interview, the facility failed to provide annual fire alarm system testing and inspection in accordance with the requirements of NFPA 101 (2012 edition), 19.3.4, 9.6, and 9.6.1.3; as well as NFPA 72 (2010 edition), Chapter 14. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 12:09 pm, review of facility fire alarm testing and inspection documents revealed annual testing and inspection exceeded the annual requirement, with the most recent testing and inspection performed on 6/10/16.

This deficient practice was confirmed by Staff C at the time of discovery.

Based on record review, observation and interview; the facility failed to provide annual fire alarm system testing and inspection in accordance with the requirements of NFPA 101 (2012 edition), 19.3.4, 9.6, and 9.6.1.3; as well as NFPA 72 (2010 edition), Chapter 14. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 2/26/18 at 12:09 pm, review of facility fire alarm testing and inspection documents revealed annual testing and inspection exceeded the annual requirement, with the most recent testing and inspection performed on 6/10/16.
2. On 2/26/18 at 3:03 pm, observation of the electrical panel containing the fire alarm circuit control revealed the main fire alarm circuit breaker was painted over with a red coating. The circuit breaker had a UL listed classification marking and a facility modification of adding a paint coating would violate the listed assembly.

Deficient practice one was confirmed by Staff C, and deficient practice two was confirmed by both Staff C and Staff U at the time of discovery.

Based on observation and staff interview, the facility did not ensure sprinkler protection is installed in all areas as required per NFPA 101 Life Safety Code (2012 edition) 19.3.5 & 9.7.1, and NFPA 13 (2010 edition). These deficient practices could affect all inpatients and an undetermined number of staff and visitors.

Findings include:

1. On 2/26/18 at 1:29 pm, observation revealed that Office #24 was not sprinkler protected. A 2' x 2' suspended ceiling tile was missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

2. On 2/26/18 at 3:07 pm, observation revealed that Corridor #2138 was not sprinkler protected. The entire suspended ceiling was missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

3. On 2/26/18 at 3:08 pm, observation revealed that Conference Room #2140 was not sprinkler protected. Two 12" x 12" suspended ceiling tiles were missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

4. On 2/26/18 at 3:09 pm, observation revealed that Closet #2139 was not sprinkler protected. Two 12" x 12" suspended ceiling tiles were missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

5. On 2/26/18 at 3:12 pm, observation revealed that Closet #2143 was not sprinkler protected. The entire suspended ceiling was missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

6. On 2/26/18 at 3:17 pm, observation revealed that Office #2153 was not sprinkler protected. The entire suspended ceiling was missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

7. On 2/26/18 at 3:30 pm, observation revealed that Closet #2079 was not sprinkler protected. The ceiling had a 3" diameter hole that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

8. On 2/26/18 at 3:17 pm, observation revealed that Nurse Station #2074 was not sprinkler protected. The entire suspended ceiling was missing that would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 101 (2012 edition) 19.3.5, and 9.7, and NFPA 13 (2010 edition) 8.1, .8.15.10.1, and 8.15.10.3 requirements, with all rooms sprinkled when the code required full sprinkling. This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 02/26/2018 at 3:00 pm it was observed in the Basement smoke compartment on the basement floor in the electrical room that the room was not sprinkler protected. The electrical room did not meet the exception requirements of a 2 Hr. rated room. The door to the room had a 45 min. rating.
The condition was confirmed at the time of discovery by a concurrent interview with Staff A (Management Services Director), and Staff T (Facility Repair Worker).
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Based on observation and interview, the facility failed to maintain its automatic sprinkler system with a specialized sprinkler wrench for each type of sprinkler in accordance with NFPA 101 (2012 edition), 19.3.5 and 9.7; and NFPA 25 (2011 edition), 5.2.1.4(2) and 5.4.1.6. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 3:08 pm, observation of the spare sprinkler cabinet located in the basement sprinkler riser room revealed no sprinkler wrench for each type of sprinkler in the facility.

The deficient practice was confirmed by Staff C and Staff U at the time of discovery.

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have 2 spare sprinklers of each type, as required by NFPA 101 (2012 edition), 9.7.5, and NFPA 25 (2011 edition). This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 02/26/2018 at 2:56 pm it was observed in the Basement smoke compartment on the basement floor in the mechanical room that there was only 1 of each type of sprinkler head for a sidewall standard response sprinkler head with a red bulb. The condition was confirmed at the time of discovery by a concurrent interview with Staff A (Management Services Director), and Staff T (Facility Repair Worker).
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Based on record review and interview, the facility failed to provide inspection of portable fire extinguishers at a minimum of 30-day intervals in accordance with NFPA 101 (2012 edition), 19.3.5.12 and 9.7.4.1; and NFPA 10 (2010 edition), 7.2.1.2 This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 12:11 pm, review of portable fire extinguisher inspection records revealed portable fire extinguisher 30-day inspection intervals were exceeded. 2017 inspection dates were as follows: 1/3/17, 2/7/17, 3/5/17, 4/2/17, 5/4/17, 6/1/17, 7/2/17, 8/2/17, 9/5/17, 10/1/17, 11/14/17 and 12/6/17. When asked, Staff B stated these inspection dates applied to all portable extinguishers in the building.

This deficient practice was confirmed by Staff B at the time of discovery.

Based on record review and interview, the facility failed to provide inspection of portable fire extinguishers at a minimum of 30-day intervals in accordance with NFPA 101 (2012 edition), 19.3.5.12 and 9.7.4.1; and NFPA 10 (2010 edition), 7.2.1.2 This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 12:11 pm, review of portable fire extinguisher inspection records revealed portable fire extinguisher 30-day inspection intervals were exceeded. 2017 inspection dates were as follows: 1/30/17, 2/28/17, 3/28/17, 4/27/17, 5/16/17, 6/29/17, 7/27/17, 8/28/17, 9/19/17, 10/26/17, 11/27/17 and 12/14/17. When asked, Staff B stated these inspection dates applied to all portable extinguishers in the building.

This deficient practice was confirmed by Staff B at the time of discovery.

Based on record review and interview, the facility failed to provide inspection of portable fire extinguishers at a minimum of 30-day intervals in accordance with NFPA 101 (2012 edition), 19.3.5.12 and 9.7.4.1; and NFPA 10 (2010 edition), 7.2.1.2 This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 12:11 pm, review of portable fire extinguisher inspection records revealed portable fire extinguisher 30-day inspection intervals were exceeded. 2017 inspection dates were as follows: 1/4/17, 2/1/17, 3/1/17, 4/6/17, 5/3/17, 6/7/17, 7/7/17, 8/2/17, 9/6/17, 10/2/17, 11/6/17 and 12/4/17. When asked, Staff B stated these inspection dates applied to all portable extinguishers in the building.

This deficient practice was confirmed by Staff B at the time of discovery.

Based on record review and interview, the facility failed to provide inspection of portable fire extinguishers at a minimum of 30-day intervals in accordance with NFPA 101 (2012 edition), 19.3.5.12 and 9.7.4.1; and NFPA 10 (2010 edition), 7.2.1.2 This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 12:11 pm, review of portable fire extinguisher inspection records revealed portable fire extinguisher 30-day inspection intervals were exceeded. 2017 inspection dates were as follows: 1/5/17, 2/3/17, 3/8/17, 4/5/17, 5/1/17, 6/6/17, 7/10/17, 8/10/17, 9/7/17, 10/3/17, 11/9/17 and 12/4/17. When asked, Staff B stated these inspection dates applied to all portable extinguishers in the building.

This deficient practice was confirmed by Staff B at the time of discovery.

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware as required by NFPA 101 (2012 edition), 19.3.6.3. This deficiency had the potential to affect 1 of the 25 patients in the Peterson Building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 02/26/2018 at 1:42 pm it was observed in the north smoke compartment on the 1st floor in resident room N228 that the corridor door would not positively self-latch. The condition was confirmed at the time of discovery by a concurrent interview with Staff A (Management Services Director), and Staff T (Facility Repair Worker).
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Based on observation and interview, the facility failed to provide smoke barrier doors with 1-3/4 inch thick solid bonded wood-core doors or construction that resists fire for 20 minutes in accordance with NFPA 101 (2012 edition), 19.3.7.6 and 8.5. This deficient practice could affect all 59 patients, as well as an undetermined number of staff and visitors.

Findings include:

On 2/26/18 at 2:39 pm, observation in the corridor at the C-101A smoke barrier revealed a pair of metal double smoke barrier doors with the door rating tags removed. No minimum 20 minute rating could be verified.

This deficient practice was confirmed by Staff U and Staff C at the time of discovery.

Based on observation and staff interview, the facility did not ensure that portable space heating devices were not being used at the facility. Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius) in accordance with NFPA 101 (2012 edition), 19.7.8. This deficient practice could affect all of the patients and an undetermined number of staff and visitors.

Findings Include:

On 2/26/18 at 3:10 pm, observation revealed a portable space heater in Office 2146. It was determined that the portable space heater would exceed 212 degrees Fahrenheit. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

Based on observation and staff interview, the facility did not ensure that fire protection features and alternative life safety measures were in place during the construction. Construction, repair, and improvement operations shall comply with 4.6.10. Buildings or portions of buildings shall be permitted to be occupied during construction only where required means of egress and required fire protection features are in place and continuously maintained in accordance with NFPA 101 (2012 edition), 19.7.9, 4.6.10, 7.1.10.1. This deficient practice could affect all of the patients and an undetermined number of staff and visitors.

Findings Include:

On 2/26/18 at 3:23 pm, observation revealed 4' x 8' plywood panels secured to 2" x 4" wood studs were used to separate the construction area from the occupied patient wing. This separation does not meet the fire rated separation criteria from a hazardous area. The ceiling was removed throughout the construction area which would affect the fire protection sprinkler function. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

Based on observation and staff interview, the facility did not ensure that extension cords are not used as a substitute for fixed wiring of a structure and that extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed, per NFPA 99 (2012 edition), 10.2.4 and NFPA 70 (2011 edition), 400.8. This deficient practice could affect all inpatients and an undermined number of staff and visitors.

Findings include:

1. On 2/26/18 at 1:17 pm, observation revealed within Office #36 that an extension cord was used to power a refrigerator and microwave oven. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

2. On 2/26/18 at 1:20 pm, observation revealed within Office #32 that an extension cord was used to power a microwave oven. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

3. On 2/26/18 at 1:27 pm, observation revealed within Office #29 that an extension cord was used to power a microwave oven and a coffee maker. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

4. On 2/26/18 at 1:28 pm, observation revealed within Office #28 that an extension cord was used to power a microwave oven and a second extension cord was used to power (2) coffee makers a coffee grinder and a hot water pot. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

5. On 2/26/18 at 1:30 pm, observation revealed within Office #23 that an extension cord was used to power (2) lamps. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

6. On 2/26/18 at 1:33 pm, observation revealed within Office #21 that an extension cord was used to power a desk lamp. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

7. On 2/26/18 at 1:36 pm, observation revealed within Housekeeping #01 that an extension cord was used to power (2) microwave ovens and a refrigerator. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

8. On 2/26/18 at 1:50 pm, observation revealed within Classroom #79 that an extension cord was used to power a refrigerator. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

9. On 2/26/18 at 1:52 pm, observation revealed within Classroom #74 that an extension cord was used to power a fan. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

10. On 2/26/18 at 2:02 pm, observation revealed within Classroom Work Area #58 that an extension cord was used to power a radio and fan. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

11. On 2/26/18 at 2:18 pm, observation revealed within Office #10 that an extension cord was used to power a refrigerator, coffee maker, toaster and radio. The condition was confirmed at the time of discovery by concurrent observationand interview with Staff B and V.

12. On 2/26/18 at 2:34 pm, observation revealed within Reception #1138C that an extension cord was used to power a radio and lamp. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

13. On 2/26/18 at 2:57 pm, observation revealed within Break Room #1085 that an extension cord was used to power a microwave oven, coffee maker and toaster. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.

14. On 2/26/18 at 3:10 pm, observation revealed within Office #2146 that an extension cord was used to power a radio and lamp. The condition was confirmed at the time of discovery by concurrent interview with Staff B and V.