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BAYPOINTE BEHAVIORAL HEALTH
Exit Signage
Tag No.: K0293
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Based on observation, the facility failed to provide continuous illumination of the exit signage per the requirements of:
2012 NFPA 101, 19.2.10.1, and 7.10.5.2.1
This deficiency affects 1 of 6 smoke compartments.
Findings include:
On 05/03/2022, during a tour of the facility from 11:30 pm to 3:30 pm, the surveyor observed the exit sign at room 710 was not illuminated.
A member of the maintenance staff was present when the deficiency was identified.
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Sprinkler System - Maintenance and Testing
Tag No.: K0353
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Based on observation and interview, the facility failed to maintain an automatic sprinkler head per the requirements of:
2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.2.1.1.1, and 5.2.1.1.2
This deficiency affects 1 of 6 smoke compartments.
Findings include:
On 05/03/2022, during a tour of the facility from 11:33 am to 3:30 pm, the surveyor observed the automatic sprinkler head in the Cooler had excessive dust and corrosion.
A member of the maintenance staff was present when this deficiency was identified.
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Portable Fire Extinguishers
Tag No.: K0355
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Based on observation, the facility failed to maintain a portable fire extinguisher per the requirements of:
2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 5.5.5.3
This deficiency affects 1 of 6 smoke compartments.
Findings include:
On 05/03/2022, during a tour of the facility from 11:30 am to 3:30 pm, the surveyor observed the K- fire extinguisher in the kitchen without the required placard/sign, stating the fire protection system shall be actuated prior to using the fire extinguisher.
A member of the maintenance staff was present when this deficiency was identified.
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Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0372
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Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:
2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3
This deficiency affects 2 of 6 smoke compartments.
Findings include:
On 05/04/2022, during a tour of the facility from 11:30 am to 3:30 pm, the surveyor observed a 2" unsealed conduit on both sides of the smoke barrier with 8 blue and black cables, above the ceiling near rooms 407 and 409.
A member of the maintenance staff was present when this deficiency was identified.