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Based on observation, the facility failed to provide exit discharges that were fully accessible in accordance with NFPA 101:7.1 and 19.2.1. This could potentially affect approximately 15 patients that utilize this facility for Work Therapy purposes.

Findings: During tour of the facility on 7/13/10 between 9:00am and 3:30pm, the rear exit to the Unit 19 Work Therapy Building was observed to exit directly into a set of stairs overgrown with vines and did not have a landing that was level with the floor surface inside.

Based on observation, the facility failed to provide exits that were readily accessible for 1 set of double doors in the building. This could potentially affect 117 of 117 patients who could utilize this facility at any time.

Findings: During tour of the facility on 7/13/10, between 9:00am and 3:30pm, the double exit doors in Class Room Evaluation #2 were hard to open during survey.

(A) Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. Observed the emergency lighting for exit discharge was not on the emergency generator for buildings 8c,and 8d .The deficient practice had the potential to affect 20 of 20 residents on 8D if it was occupied, and 2 of 2 smoke compartments had deficient emergency lighting.
(B.) Based on visual inspection the facility failed to provide emergency lighting along the entire length of the a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. Observed the emergency exit discharge lighting at all the exits where not on emergency generator and did not have dual fixtures on 8C. This deficient condition has the potential to affect 2 of two smoke compartments and 7 patients on the 8C building

Findings:

(A.) During the facility tour, on 7/11/2010 between the hours of 8;00 A.M. and 4:30 P.M. it was observed that the emergency discharge lighting at the exit doors did not have a two fixture light in place and were not on emergency generator power on building 8D.
(B) During the facility tour, on 7/11/2010 between 8;00 A.M. and 4:30 P.M. observed the emergency discharge lighting at all exit doors was not on emergency generator and they where not dual light fixtures.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor the sleeping area. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 30 of 30 residents on the 7B building and 28 residents on the 7C building.
1 of 2 corridors has emergency lighting that is deficient on the &B building and 1 of 2 halls on the 7 C building.

Findings:

During the facility tour on 7/12/2010 between the hours of 8:00 A.M. and 4:30 P.M. it was observed that the emergency lighting in the exit corridor of building 7B one of two bulbs was not working. The exit discharge lighting at the exit doors were not connected to the generator and did not all have two bulbs in the event one would burn out on both 7 B, and 7C buildings.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor the sleeping area. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 0 of 32 patients on the Unit 11 building.

Findings: During tour of the facility on 7/13/10, between 9:00am and 3:30pm, all of the exit discharges were observed to not be on emergency power and had only a single light bulb for the fixtures instead of the required 2 bulbs.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor the sleeping area. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 47 of 52 patients on the 9A, 9B, and 9C buildings.

Findings: During tour of the facility on 7/13/10, between 9:00am and 3:30pm, all of the exit discharges were observed to not be on emergency power and had only a single light bulb for the fixtures instead of the required 2 bulbs.

Based on visual observation, the facility failed to assure that all smoking areas were supplied with a metal, self-closing container. Cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion. This deficient practice could potentially affect 58 of 58 residents.

Findings:

During the facility tour, on 7/12/2010 between the hours of 8:00 a.M. and 4:30 P.M. observed there was no metal self closing container in the smoking area covered pavilion just outside 7 B,C and A buildings.

Based on visual observation (A.) the facility failed to maintain The 8c smoke damper. It failed to close upon activation of the duct detector that controls it and is out of adjustment as it partially close when duct detector in hall was activated. The deficient practice had the potential to affect 2 of 2 smoke compartments, and approximately 20 beds if it was occupied.
Based on visual inspection (B.) the facility failed to maintain the 8D smoke damper. It failed to close when activated by the duct detector. The deficient practice had the potential to affect 2 of 2 smoke compartments and 20 licensed bed if it where occupied. This building was empty at time of survey.

Findings:

(A.) During the facility tour on 7/11/2010, between the hours of o8:00 A.M. and 4:30 P.M. (hours of survey), it was observed that the 8c duct detector failed to close a smoke damper when activated and was found out of adjustment when it partially close by activation by the duct detector in the hall.
(B.) During the facility tour on 7/11/2010 between 8:00 A.M. and 4:30 P.M. it was observed that the smoke damper in 8D failed to close upon duct detector activation in room 118 .

Based on visual observation the facility failed to maintain The 9C smoke damper. It failed to close upon activation of the duct detector that controls it. The deficient practice had the potential to affect 2 of 2 smoke compartments, and 28 of 28 patients.

Findings:

During the facility tour on 7/13/2010, between the hours of 9:00 A.M. and 3:30 P.M. (hours of survey), it was observed that the 9C duct detector failed to close a smoke damper when activated.

Based on observation, the facility failed to provide an emergency generator that operates in accordance with NFPA 99 and NFPA 110. This could potentially affect 47 of 52 patients in 9A, 9B, and 9C in the event of an actual power failure.

Findings: During a tour of the facility on 7/13/10 between 9:00AM AND 3:30PM, a test was conducted on the emergency generator for Units 9A, 9B, and 9C. The facility electrician turned the main breaker to the buildings off to simulate a power failure and it was 15 second before power was restored to the building.

Actual NFPA Standard:
NFPA 99: 3-5.3.1 Source.
The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source.

Based on observation, the facility failed to provide exit discharges that were fully accessible in accordance with NFPA 101:7.1 and 19.2.1. This could potentially affect approximately 15 patients that utilize this facility for Work Therapy purposes.

Findings: During tour of the facility on 7/13/10 between 9:00am and 3:30pm, the rear exit to the Unit 19 Work Therapy Building was observed to exit directly into a set of stairs overgrown with vines and did not have a landing that was level with the floor surface inside.

Based on observation, the facility failed to provide exits that were readily accessible for 1 set of double doors in the building. This could potentially affect 117 of 117 patients who could utilize this facility at any time.

Findings: During tour of the facility on 7/13/10, between 9:00am and 3:30pm, the double exit doors in Class Room Evaluation #2 were hard to open during survey.

(A) Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. Observed the emergency lighting for exit discharge was not on the emergency generator for buildings 8c,and 8d .The deficient practice had the potential to affect 20 of 20 residents on 8D if it was occupied, and 2 of 2 smoke compartments had deficient emergency lighting.
(B.) Based on visual inspection the facility failed to provide emergency lighting along the entire length of the a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. Observed the emergency exit discharge lighting at all the exits where not on emergency generator and did not have dual fixtures on 8C. This deficient condition has the potential to affect 2 of two smoke compartments and 7 patients on the 8C building

Findings:

(A.) During the facility tour, on 7/11/2010 between the hours of 8;00 A.M. and 4:30 P.M. it was observed that the emergency discharge lighting at the exit doors did not have a two fixture light in place and were not on emergency generator power on building 8D.
(B) During the facility tour, on 7/11/2010 between 8;00 A.M. and 4:30 P.M. observed the emergency discharge lighting at all exit doors was not on emergency generator and they where not dual light fixtures.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor the sleeping area. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 30 of 30 residents on the 7B building and 28 residents on the 7C building.
1 of 2 corridors has emergency lighting that is deficient on the &B building and 1 of 2 halls on the 7 C building.

Findings:

During the facility tour on 7/12/2010 between the hours of 8:00 A.M. and 4:30 P.M. it was observed that the emergency lighting in the exit corridor of building 7B one of two bulbs was not working. The exit discharge lighting at the exit doors were not connected to the generator and did not all have two bulbs in the event one would burn out on both 7 B, and 7C buildings.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor the sleeping area. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 0 of 32 patients on the Unit 11 building.

Findings: During tour of the facility on 7/13/10, between 9:00am and 3:30pm, all of the exit discharges were observed to not be on emergency power and had only a single light bulb for the fixtures instead of the required 2 bulbs.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor the sleeping area. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 47 of 52 patients on the 9A, 9B, and 9C buildings.

Findings: During tour of the facility on 7/13/10, between 9:00am and 3:30pm, all of the exit discharges were observed to not be on emergency power and had only a single light bulb for the fixtures instead of the required 2 bulbs.

Based on visual observation, the facility failed to assure that all smoking areas were supplied with a metal, self-closing container. Cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion. This deficient practice could potentially affect 58 of 58 residents.

Findings:

During the facility tour, on 7/12/2010 between the hours of 8:00 a.M. and 4:30 P.M. observed there was no metal self closing container in the smoking area covered pavilion just outside 7 B,C and A buildings.

Based on visual observation (A.) the facility failed to maintain The 8c smoke damper. It failed to close upon activation of the duct detector that controls it and is out of adjustment as it partially close when duct detector in hall was activated. The deficient practice had the potential to affect 2 of 2 smoke compartments, and approximately 20 beds if it was occupied.
Based on visual inspection (B.) the facility failed to maintain the 8D smoke damper. It failed to close when activated by the duct detector. The deficient practice had the potential to affect 2 of 2 smoke compartments and 20 licensed bed if it where occupied. This building was empty at time of survey.

Findings:

(A.) During the facility tour on 7/11/2010, between the hours of o8:00 A.M. and 4:30 P.M. (hours of survey), it was observed that the 8c duct detector failed to close a smoke damper when activated and was found out of adjustment when it partially close by activation by the duct detector in the hall.
(B.) During the facility tour on 7/11/2010 between 8:00 A.M. and 4:30 P.M. it was observed that the smoke damper in 8D failed to close upon duct detector activation in room 118 .

Based on visual observation the facility failed to maintain The 9C smoke damper. It failed to close upon activation of the duct detector that controls it. The deficient practice had the potential to affect 2 of 2 smoke compartments, and 28 of 28 patients.

Findings:

During the facility tour on 7/13/2010, between the hours of 9:00 A.M. and 3:30 P.M. (hours of survey), it was observed that the 9C duct detector failed to close a smoke damper when activated.

Based on observation, the facility failed to provide an emergency generator that operates in accordance with NFPA 99 and NFPA 110. This could potentially affect 47 of 52 patients in 9A, 9B, and 9C in the event of an actual power failure.

Findings: During a tour of the facility on 7/13/10 between 9:00AM AND 3:30PM, a test was conducted on the emergency generator for Units 9A, 9B, and 9C. The facility electrician turned the main breaker to the buildings off to simulate a power failure and it was 15 second before power was restored to the building.

Actual NFPA Standard:
NFPA 99: 3-5.3.1 Source.
The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source.