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42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

There are holes in the cross corridor smoke barrier between room 109 and therapist office.

NFPA 101, 19.3.7.3, 19.3.7.5, 8.3


This deficiency potentially affects one of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The facility had unsealed penetrations in the rated ceilings at the following locations:

1. The ceiling of the gas fired hot water heater room.
2. The ceiling and corridor wall of the maintance / main electrical room.

NFPA 101, 19.3.2.1; 8.2.4.4.1

This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The front entrance exit door utilizes an electromagnetic lock, without a key switch adjacent to door release hardware for rapid removal of ocupants in the event of an emergency.

NFPA 101, 18.2.4.1, 18.2.4.2, 19.2.4.1, 19.2.4.2


This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

There is dust and debris accumulation on duct smoke detector sampling tubes - located above corridor ceiling between room 109 and therapist office.

NFPA 101, 9.6.1.3


This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

Main sprinkler control valves in outside valve pit are monitored by non-listed supervisory switches. Existing switches use cord and plug arrangement not permitted for NFPA 13 Sprinkler system supervision.

NFPA 101, 9.7.2.1


This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The sprinkler tamper switch supervisory signal fails to sound with main control valve in the closed position. The audible signal could be silenced with the valve in the closed position.

NFPA 101, 9.7.2.1


This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

Blow-off caps are missing from range hood fire suppression nozzles located above cooking equipment in kitchen area.

NFPA 101, 19.3.2.6, NFPA 96, 9.2.3


This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The facility has unsecured carbon dioxide cylinders in the dry storage room across from the dietary department. Gas cylinders should be properly and individually chained or supported in a proper cylinder stand or cart.

NFPA 101, 19.3.2.4
NFPA 99, 4-3.5.21(b) 27

This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

1. The loss of normal power to generator automatic transfer switch required greater than ten seconds to restore power to the facility.

2. There is no generator annunciator panel to monitor emergency power supply system in the Adams Building.

NFPA 99, 3-4.4.1, 8-4.2


This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The EPS supplying load indicator did not function with test of the emergency power supply system. The generator annunciator panel failed to function properly with automatic transfer switch "ES" in emergency mode.

NFPA 99, 3-4.4.1,and NFPA 110, Chapter 6


This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The facility maintenance and inspection of emergency power system was non-compliant, specific findings include:
1. The emergency power system generator located on the exterior of the building does not have a remote manual stop switch located outside the generator housing unit. All level 1 and level 2 generator instillation's shall have a remote manual stop station located other than where the prime generator is located.
2. The facility has exposed electrical wiring inside the generator housing unit that were not enclosed in an electrical junction box.

Ref: 2000 NFPA 101 Section 18.5.1
NFPA 99. 3-5.5.6

This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

There are holes in the cross corridor smoke barrier between room 109 and therapist office.

NFPA 101, 19.3.7.3, 19.3.7.5, 8.3


This deficiency potentially affects one of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The facility had unsealed penetrations in the rated ceilings at the following locations:

1. The ceiling of the gas fired hot water heater room.
2. The ceiling and corridor wall of the maintance / main electrical room.

NFPA 101, 19.3.2.1; 8.2.4.4.1

This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The front entrance exit door utilizes an electromagnetic lock, without a key switch adjacent to door release hardware for rapid removal of ocupants in the event of an emergency.

NFPA 101, 18.2.4.1, 18.2.4.2, 19.2.4.1, 19.2.4.2


This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

There is dust and debris accumulation on duct smoke detector sampling tubes - located above corridor ceiling between room 109 and therapist office.

NFPA 101, 9.6.1.3


This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

Main sprinkler control valves in outside valve pit are monitored by non-listed supervisory switches. Existing switches use cord and plug arrangement not permitted for NFPA 13 Sprinkler system supervision.

NFPA 101, 9.7.2.1


This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The sprinkler tamper switch supervisory signal fails to sound with main control valve in the closed position. The audible signal could be silenced with the valve in the closed position.

NFPA 101, 9.7.2.1


This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

Blow-off caps are missing from range hood fire suppression nozzles located above cooking equipment in kitchen area.

NFPA 101, 19.3.2.6, NFPA 96, 9.2.3


This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The facility has unsecured carbon dioxide cylinders in the dry storage room across from the dietary department. Gas cylinders should be properly and individually chained or supported in a proper cylinder stand or cart.

NFPA 101, 19.3.2.4
NFPA 99, 4-3.5.21(b) 27

This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

1. The loss of normal power to generator automatic transfer switch required greater than ten seconds to restore power to the facility.

2. There is no generator annunciator panel to monitor emergency power supply system in the Adams Building.

NFPA 99, 3-4.4.1, 8-4.2


This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The EPS supplying load indicator did not function with test of the emergency power supply system. The generator annunciator panel failed to function properly with automatic transfer switch "ES" in emergency mode.

NFPA 99, 3-4.4.1,and NFPA 110, Chapter 6


This deficiency potentially affects one of five smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on June 21, 2016 at approximately 8:00AM onward, the following deficiencies were noted: The standard is s non-compliant, specific findings include:

The facility maintenance and inspection of emergency power system was non-compliant, specific findings include:
1. The emergency power system generator located on the exterior of the building does not have a remote manual stop switch located outside the generator housing unit. All level 1 and level 2 generator instillation's shall have a remote manual stop station located other than where the prime generator is located.
2. The facility has exposed electrical wiring inside the generator housing unit that were not enclosed in an electrical junction box.

Ref: 2000 NFPA 101 Section 18.5.1
NFPA 99. 3-5.5.6

This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.