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Based on observation and staff interview the facility failed to ensure controlled-egress lock doors released during a fire alarm test in accordance with NFPA 101 - 2012 Edition, Section 19.2.2.2.5.2*. This has the potential to affect all patients. This facility census was 17.

Findings include:

Observation on 05/07/19 at 1:53 P.M., during the fire alarm test, noted the application of controlled-egress doors throughout the facility. Observation of the exit door at the end of the Acute Wing corridor, revealed the door was equipped with a electronic release lock, and when tested during the activation of a fire alarm, did not immediately release. The door did release with the staff key fob when the fire alarm system was reset to the normal position.

Interview with Facilities Director #10 and Maintenance Director #11 verified the electronic door locks failed to release during the fire alarm system test.

Based on observation and staff interview, the facility failed to ensure exit walkways were provided with a walk surface to the public way in accordance with the requirements of NFPA 101-2012 Edition, Sections 19.2.1 and 7.1.6.2; 7.7.1; 7.7.1.1. This has the potential to affect all patients. This facility census was 17.
Findings include:
Observation on 05/07/19 at 11:35 A.M., during tour of the facility, noted the integrity of the emergency exit discharges, to the public way, throughout the facility. Examination of the Acute corridor and the Gym exit revealed the exit doors, which led directly to the exterior, terminated at the four foot by four foot concrete pad. The walking surface was discovered with an abrupt four inch elevation change to the grass landscape and the walkway failed to terminate to the public way. The Gym exit discharge location was measured 282 feet to the asphalt parking lot and the Acute corridor exit was measured 124 feet to the asphalt parking lot.
Interview with Facilities Director #10 and Maintenance Director #11 verified the findings at the time of discovery.

Based on observations, record review and interview the facility failed to ensure hazardous area separations were maintained in accordance with NFPA 101-19.3.2.1; 19.3.2.1.3; 19.3.2.1.5. This has the potential to affect all patients. This facility census was 17.

Findings include:

Observation on 05/07/19 at 10:15 A.M., during tour of the facility, noted the integrity of the hazardous area storage rooms throughout the facility. Examination of the Acute Storage Room #104, revealed the room contained 11 cardboard boxes, 17 plastic totes with clothes, and a covered clean linen cart, measured over 50 square feet, and was not provided with self or automatic door closer.

Record review on 05/06/19 at 8:45 A.M. of the provided life safety schematics verified the room was approved for storage.

Interview with Facilities Director #10 and Maintenance Director #11 verified the findings at the time of discovery.

Based on observation and interview the facility failed to maintain fire alarm smoke detectors in accordance with NFPA 101-2012 Edition, Section 9.6.1.3; NFPA 72-2010 Edition, Sections 17.7.4.1*; 18.3.3.1. This has the potential to affect all patients. This facility census was 17.

Findings include:

Observation on 05/06/19 and 05/07/19 between 9:15 A.M. and 3:45 P.M., during tour of the facility, noted the integrity of the spot type fire alarm interconnected smoke detectors throughout the facility. Examination of the Gym Floor Cleaning Room revealed the ceiling smoke detector was installed within 17 inches of the heating ventilation air conditioning supply vent (HVAC). In addition, the ceiling smoke detector installed inside the Maintenance Shop was discovered with a protective orange cover, which prevented the detector from activation.

Interview with Facilities Director #10 (FD#10) and Maintenance Director #11 (MD#11) verified the findings at the time of discovery. FD#10 confirmed the cover was placed on the detector during sanding of equipment and was never removed after completion.

Based on observation and interview the facility failed to ensure the sprinkler system, spare sprinkler head storage and combustible storage were maintained in accordance with NFPA 101-2012 Edition, Section 101-2012 Edition, Section 9.7.1.1*; NFPA 13-2010 Edition, Section 8.5.6.1*; NFPA 25-2011 Edition, Section 5.4.1.4.2.This has the potential to affect all patients. This facility census was 17.

Findings include:

Observation on 05/06/19 and 05/07/19 between 9:15 A.M. and 3:45 P.M. noted the integrity of the sprinkler system and sprinkler system components throughout the facility.

1. Observation on 05/07/19 at 2:40 P.M. inside the Gym Storage Room revealed one concealed sprinkler cap was painted to the ceiling.
2. Observation on 05/07/19 at 2:42 P.M. inside Gym Storage Room and the Gym Floor Cleaning Room revealed combustible storage within 18 inches of the sprinkler head deflector.
3. Observation on 05/08/19 at 9:35 A.M. inside the sprinkler riser room revealed four spare sprinkler heads stored outside the provided wall mounted sprinkler cabinet.
4. Observation on 05/08/19 at 9:50 A.M. inside the Kaftan Case Manager Office noted combustible storage boxes stored within 18 inches of the sprinkler heads.

Interview with Facilities Director #10 and Maintenance Director #11 verified the findings at the time of discovery.

Based on observation and interview the facility failed to ensure smoke and fire barriers could resist the passage of smoke in accordance with NFPA 101-2012 Edition, Sections 8.5.6.2; 19.3.7.3. This has the potential to affect all patients. This facility census was 17.

Findings include:

Observation on 05/06/19 and 05/07/19 between 9:15 A.M. and 3:45 P.M., during tour of the facility noted integrity of the smoke and fire rated barrier assemblies throughout the facility.

1. Observation on 05/07/19 at 10:45 A.M. from the corridor, in the above suspended ceiling space, at the Gym entrance door, revealed two sections of missing concrete block around the angular space of two insulated water pipes, which measure one and one half inches.

2. Observation on 05/07/19 at 10:55 A.M. from the Celso Hall corridor, in the above suspended ceiling space, at the cross corridor double fire doors, revealed a two inch section of exposed insulation and lacked fire resistant spay at the roof deck.

Interview with Maintenance Director #11 verified the findings at the time of discovery.

Based on observation, record review and interview the facility failed to ensure rated fire door assemblies latched in accordance with NFPA 101-2012 Edition, Section 8.3.3.1; NFPA 80-2010 Edition, Section 5.2.4.2.(8) This has the potential to affect all patients. This facility census was 17.

Findings include:

Observation on 05/07/18 between 9:15 A.M. and 2:30 P.M., during tour of the facility, noted the integrity of the rated 90 minute fire doors throughout the facility. Examination of the fire doors in the Acute, Celso, Meena and Sathpan corridors revealed the cross corridor fire doors were equipped with electronic door strikes, which deactivate via staff key fob or fire alarm activation. However, during the fire alarm test, the doors failed to properly latch into the frames, as required. The doors were labeled as 90 minute fire doors.

Record review on 05/06/19 at 8:45 A.M. of the provided life safety schematics verified the patients occupy the center Acute, Celso, Meena, Sathpan smoke compartment.

Interview with Facilities Director #10 and Maintenance Director #11 verified the findings at the time of discovery.

Based on observation and interview the facility failed to ensure flexible cord power strips and extension cords were maintained in accordance with NFPA 99-2012 Edition, Section 10.2.3.6. This has the potential to affect all patients. This facility census was 17.


Findings include:

Observation on 05/06/19 and 05/07/19 between 9:15 A.M and 3:45 P.M., during tour of the facility, noted the application of flexible cord power strips throughout the facility.

1. Observation on 05/06/19 at 2:15 P.M. under the front lobby reception desk revealed a power strip plugged into another power strip.

2. Observation on 05/06/19 at 2:20 P.M. inside Office #14 revealed a power strip plugged into another power strip.

3. Observation on 05/06/19 at 2:30 P.M. inside Office #124 revealed an overloaded electrical outlet contained a multi-plug adapter.

4. Observation on 05/06/19 at 3:11 P.M. inside the Human Resources Office discovered a refrigerator plugged into a power strip.

5. Observation on 05/06/19 at 3:20 P.M. inside Training Room #9 noted a microwave and refrigerator plugged into two power strips.

6. Observation on 05/06/19 at 3:45 P.M. inside Office #38 noted a two wire ungrounded extension plugged into the wall outlet.

Interview with Facilities Director #10 verified the findings at the time of discovery.