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Based on observation and interview, the facility failed to provide illumination of means of egress along the exit discharge path outside 1 of 2 exit doors (end of hallway exit) from the boy's unit, in accordance with NFPA 101, 7.8.1.1, 7.8.1.2, and 7.8.1.4, as referenced by NFPA 101, 19.2.8.

This failure could delay egress in the event of an emergency evacuation and potentially adversely affect the safety of the building's occupants.

Findings included:

During observations and interviews on 05/30/24, in the boy's unit of the facility, the exit door at the end of the hallway led to a fenced-in courtyard with a gate. There was a pathway and ramp from the exit door to the gate and parking lot. There were no lighting fixtures outside the exit door (minimum 2 sources required) nor anywhere along the ramp to provide illumination along the exit discharge path that was part of the required means of egress. The Environment of Care Director confirmed the observations when the surveyor discussed the finding.

Based on observation and interview, the facility failed to provide emergency lighting of the means of egress along the exit discharge path outside 1 of 2 exit doors (end of hallway exit) from the boy's unit, in accordance with NFPA 101, 7.9, 7.9.1.1, and 7.9.1.2, as referenced by NFPA 101, 19.2.9.1.

This failure could delay egress in the event of an emergency evacuation and potentially adversely affect the safety of the building's occupants.

Findings included:

During observations and interviews on 05/30/24, in the boy's unit of the facility, the exit door at the end of the hallway led to a fenced-in courtyard with a gate. There was a pathway and ramp from the exit door to the gate and parking lot. There were no lighting fixtures outside the exit door (minimum 2 sources required) nor anywhere along the ramp to illuminate the exit discharge path, that were powered by the Life Safety branch of the essential electrical system. The Environment of Care Director confirmed the observations when the surveyor discussed the finding.

Based on observation and interview, the facility failed to protect 1 of 1 mechanical room (located off the receiving hallway) with continuous smoke resisting partitions, in accordance with NFPA 101, 19.3.2.1 and 8.4.2.

This failure could permit fire/smoke to spread to adjacent areas and potentially adversely affect the safety of the building's occupants in the event of a fire.

Findings included:

During observations and interviews on 05/29/24, in the mechanical room containing boilers located off the receiving hallway, the left wall was not continuous to the floor. There was an approximate 6" tall section of the outer gypsum board layer missing along the base of the wall behind the boilers. The Director of Environment of Care confirmed the observations in the mechanical room when the surveyor discussed the findings.

Based on observation, interview, and record review, the facility failed to maintain 1 of 1 fire suppression hood system (in the kitchen), in accordance with NFPA 17A, 4.3.1.5 and 7.2, as referenced by NFPA 96, 10.2.6(4) and NFPA 101, 19.3.2.5.1 and 9.2.3, as follows:

*blow off caps or covers were not provided on all the discharge nozzles, and

*monthly quick check inspections were not conducted.

These failures could affect the reliability of the fire suppression hood system and potentially adversely affect the safety of the building's occupants in the event of a cooking related fire in the kitchen.

Findings included:

During observations, interviews, and record reviews on 05/30/24, the following were noted regarding the fire suppression hood system over the commercial cooking range in the kitchen:

*All of the fire suppression discharge nozzles underneath the range hood did not have any covers or blow off caps installed to prevent grease or foreign materials from entering the piping.

*The inspection tag at the manual pull actuator for range hood fire suppression system did not contain any dates or initials of a person performing quick check inspections.

The facility's Life Safety and maintenance records did not include any other documentation that quick check inspections (owner performed) for the kitchen's fire suppression hood system. The Director of Environment of Care confirmed the observations of the kitchen hood's fire suppression system when the surveyor discussed the findings.

Based on observation and interview, the facility failed to provide manual fire alarm pull stations at exit doors in 2 of 4 patient units (boy's unit and girl's unit), in accordance with NFPA 101, 19.3.4.2.1, 9.6.2, and 9.6.3.

This failure could delay initiation of the fire alarm system in the event of a fire or emergency and potentially adversely affect the safety of the building's occupants.

Findings included:

During observations and interviews on 05/30/24, there was no manual fire alarm pull station at either the exterior exit door at the end of the hallway or at the nurse station in the boy's unit. Additionally, there was no manual fire alarm pull station at the either the exterior exit door at the end of the hallway or at the nurse station in the girl's unit. The Director of Environment of Care confirmed the lack of manual fire pull stations when the surveyor discussed the findings.

Based on observation and interview, the facility failed to maintain 1 of 1 fire sprinkler system, in accordance with NFPA 25, 5.2.1.1.2(5). 5.2.1.1.4, 5.4.1.4, and 5.4.1.5, as follows:

*Seven individual fire sprinkler heads were not maintained free of foreign material or dust,

*Provide spare sprinkler heads for each type of sprinkler installed, and

*Three individual sprinkler heads were missing their escutcheon plates.

This failure could delay activation of fire sprinkler heads and potentially adversely affect the safety of the building's occupants in the event of a fire or emergency.

Findings included:

During observations and interviews on 05/29/24 and 05/30/24, the following were noted regarding the building's fire sprinkler system:

*Five fire sprinkler heads surrounding cooking range hood in the kitchen had foreign material buildup and/or dust on their deflectors and response elements.

*The sprinkler head near the pots/pans shelves in the kitchen, the sprinkler head in the kitchen pantry, and the sprinkler head in the transition hall outside the electrical room, were each missing an escutcheon plate.

*The fire sprinkler head in the kitchen dishwashing area had discoloration and foreign material buildup.

*The fire sprinkler head in the first laundry closet in the girl's unit was loaded with dust.

*There were no spare sprinkler heads provided for the upright extended coverage type sprinkler heads (installed in the gym) or the standard spray pendant type (ordinary temperature, quick response element) sprinkler heads.

The Director of Environment of Care confirmed the observations of the sprinkler heads when the surveyor discussed the findings.

Based on observation, interview, and record, the facility failed to:

*Conduct inspections at minimum 30 day intervals for 22 of 22 fire extinguishers located throughout the facility, in accordance with NFPA 10, 7.2.1.2 and 7.2.4.1.

*Conspicuously identify fire extinguishers in cabinets located in all hallways throughout the facility, in accordance with NFPA 10, 6.1.3.1 and 6.1.3.10.2.

This failure could delay extinguishment of a fire in an emergency and potentially adversely affect the safety of the building's occupants.

Findings included:

During observations and interviews on 05/29/24 and 05/30/24, the following were noted:

*The inspection tags on fire extinguishers located throughout the facility did not contain any initial and dates of a person performing inspections at minimum 30 day intervals. The facility's Life Safety plan indicated 22 fire extinguishers located throughout the hospital. The facility's maintenance records did not include any other documents that inspections (minimum 30 day intervals) of the fire extinguishers were conducted.

*Fire extinguishers in hallways throughout the facility were located in recessed cabinets in the wall and were not identified with signage or markings that were identifiable when viewed from down the hallways. The Director of Environment of Care confirmed the observations of the fire extinguishers when the surveyor discussed the findings.

Based on observation and interview, the facility failed to ensure 2 of 5 smoke barrier walls (transition and boy's unit) were constructed to a ½ hour fire resistance rating and resisted the passage of smoke, in accordance with NFPA 101, 19.3.7.3 and 8.5.

This failure could compromise the integrity of the smoke barrier wall and permit smoke/fire to transfer from one smoke compartment to another in the event of a fire and potentially adversely affect the safety of the patients.

Findings included:

During observations and interviews on 05/30/24, the following were noted:

*Above the smoke barrier doors to the transition hall, there was a 2-inch by 2-inch opening in the wall.

*Above the hallway smoke barrier doors to boy's unit, there was a 5-inch by 5-inch hole in the wall and a 2-inch by 3-inch cutout in the wall with an unsealed wire penetration through it.

*Above the ceiling of the staff lounge smoke barrier wall in the boy's unit, there was a 3-inch by 3-inch opening in the wall.

The Director of Environment of Care confirmed the observations regarding the building's smoke barrier walls when the surveyor discussed the findings.

Based on interview and record, the facility failed to conduct fire drills for 4 of 4 quarters each year for each work shift, in accordance with NFPA 101, 19.7.1.6.

This failure could prevent prompt and effective staff response in the event of a fire or emergency and potentially adversely affect the safety of the building's occupants.

Findings included:

During interviews and record reviews on 05/30/24, the Director of Quality and Risk Management said there were 2 different staff work shifts, 1st and 2nd shifts. The only fire drill documentation available was for a fire drill conducted in March 2024 for the 2nd shift. The Director of Quality and Risk Management said the previous fire drill documentation could not be located and there was no other documentation for previous conducted fire drills available.

Based on observation and interview, the facility failed to:

*Locate exhaust discharges at least 25 feet away from the air intake for 2 of 2 rooftop air handler units (serving the boy's unit and girl's unit), in accordance with ASHRAE 170, 6.3.1.1 as referenced by NFPA 99 9.3.3.1.

*Locate the outside air intake height for 3 of 3 air handler units (serving the resilience unit, perseverance unit, and gymnasium) at least 6 feet above the ground, in accordance with ASHRAE 170, 6.3.1.1 as referenced by NFPA 99 9.3.3.1.

*Provide positive air pressure in the medication room and clean linen room in 2 of 4 patient units (boy's unit and girl's unit), in accordance with ASHRAE 170, 7.1, Table 7-1 as referenced by NFPA 99 9.3.3.1.

This failure could affect the indoor air quality and potentially adversely affect the health and safety of the building's occupants.


Findings included:

During observations and interviews on 05/30/24, the following were noted:

*On the roof, the rooftop air handler unit serving the boy's unit had an exhaust fan located within approximately 15 feet from the unit's air intake vents.

*On the roof, the rooftop air handler unit serving the girl's unit had an exhaust fan located within approximately 15 feet from the unit's air intake vents.

*The air handler unit serving the gymnasium had the bottom of its outside air intake vent located less than 1 foot off the ground.

*The air handler unit serving the resilience patient unit had the bottom of its outside air intake vent located approximately 18-inches off the ground.

*The air handler unit serving the perseverance patient unit had the bottom of its intake vent located approximately 18-inches off the ground.

*In the medication room and clean linen room (located in the nurse station area) in the boy's unit, there was no positive air supply functioning in each of the rooms.

*In the medication room and clean linen room (located in the nurse station area) in the girl's unit, there was no positive air supply functioning in each of the rooms.

The Director of Environment of Care confirmed the observations of the air handler units and lack of airflow in the medication and clean linen rooms when the surveyor discussed the findings.

Based on observation, interview, and record, the facility failed to maintain 1 of 1 generator (providing emergency power for the hospital) as follows:

*Appurtenant components were not inspected at least weekly, in accordance with NFPA 110, 8.3.4, 8.4, and 8.4.1.

*Testing was not conducted under load at least monthly for at least 30 minutes, including operating the transfer switches, in accordance with NFPA 110, 8.4, 8.4.1, 8.4.2.

This failure could affect the reliability of the emergency power system during a power outage and potentially adversely affect the safety of the building's occupants.

Findings included:

During observations, interviews, and record reviews on 05/29/24 and 05/30/24, the following were noted:

*A generator and automatic transfer switches were installed that provided emergency power to the hospital.

*Weekly generator appurtenant components inspection logs available for review were dated 04/26/24, 05/06/24, 05/14/24, and 05/20/24. There was other no documentation for prior months that the generator's appurtenant components were inspected weekly.

*There was only one monthly generator testing log available dated 05/24/24 that indicated the generator was only run for 13 minutes including a 10-minute cool down time. There was other no documentation for prior months that the generator was tested under load for at least 30 minutes on a monthly basis.

The Director of Environment of Care confirmed the observations regarding maintenance and testing of the generator when the surveyor discussed the findings, and said that no other weekly or monthly generator logs were available.