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This Standard is not met as evidenced by:

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. These deficient practices have the potential of affecting three (3) of three (3) smoke compartments. This condition has the potential to affect all residents and staff in the facility at the day/time of survey.

Finding include:

While inspecting smoke barrier walls on 1/5/16 at 11:45 AM, observations revealed these smoke barrier walls had the following unsealed penetrations in the following area:

1. Smoke barrier wall separating the Old Hospital Wing from the Behavioral Health Unit had large open holes in masonry wall.

2. Smoke barrier wall between Old Hospital Wing New Hospital Wing had multiple unsealed penetrations and also other penetrations sealed by an unapproved, combustible material (FOAM) spray.

The maintenance director was notified during the survey and in the exit conference.

This standard is not met as evidenced by;

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1.and all states letter Ref: S&C -07-05.
These deficient practice had the potential of affecting one (1) of three (3) smoke compartments.

Findings Include:

On 1/5/16 at 1:00 PM, observation revealed one (1) of seven (7) required exits to be inaccessible. The South Exit near helicopter pad lacked an all weather surface leading to the public way.

The maintenance director was notified during the survey and in the exit conference.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This Standard is not met as evidenced by:

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. These deficient practice had the potential of affecting one (1) of three (3) smoke compartments.


Findings include:

On 1/5/16 at 11:50 AM, observation revealed no emergency strobe light and horn system were installed on the A Hall of the Behavioral Health Unit of the facility.

The maintenance director was notified during the survey and in the exit conference.

This standard is not met as evidenced by:

Based on observations, the facility failed to conduct the required test of the sprinkler system as required by NFPA 25 section 9.7.5. This deficiency had potential to affect the entire facility on the day of the survey.

Findings Include:

On 1/5/16 at 1:00 PM, the facility was unable to provide records/documentation for the the quarterly and annual testing of the automatic sprinkler system.

The maintenance director was notified during the survey and in the exit conference.

This standard is not met as evidenced by:

Based on observations, the facility failed to conduct the required test of the hood kitchen system as required by NFPA 96. This deficiency had potential to affect the entire facility on the day of the survey.

Findings Include:

On 1/5/16 at 12:45 PM, the facility was unable to provide the last two (2) inspections for the the testing and maintenance of the Kitchen commercial hood system and components.

The maintenance director was notified during the survey and in the exit conference.

NFPA 18.3.2.6 Cooking Facilities.
Cooking facilities shall be protected in accordance with 9.2.3.

NFPA 9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NNFPA 96 8-2 Inspection.
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

This Standard is not met as evidenced by:

Based on record review, the facility failed to maintain the generator as required in NFPA 110 section 6.4.2. This deficiency had potential to affect the entire facility on the day of the survey.

Findings include:

1. On 1/5/16 at 1:05 PM, the facility was unable to provide documentation of the monthly load testing and weekly inspections of the generator.

The maintenance director was notified during the survey and in the exit conference.

NFPA 110, 6-4.2 required generator to be exercised under load for 30 minutes monthly.

This Standard is not met as evidenced by:

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. These deficient practices have the potential of affecting three (3) of three (3) smoke compartments. This condition has the potential to affect all residents and staff in the facility at the day/time of survey.

Finding include:

While inspecting smoke barrier walls on 1/5/16 at 11:45 AM, observations revealed these smoke barrier walls had the following unsealed penetrations in the following area:

1. Smoke barrier wall separating the Old Hospital Wing from the Behavioral Health Unit had large open holes in masonry wall.

2. Smoke barrier wall between Old Hospital Wing New Hospital Wing had multiple unsealed penetrations and also other penetrations sealed by an unapproved, combustible material (FOAM) spray.

The maintenance director was notified during the survey and in the exit conference.

This standard is not met as evidenced by;

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1.and all states letter Ref: S&C -07-05.
These deficient practice had the potential of affecting one (1) of three (3) smoke compartments.

Findings Include:

On 1/5/16 at 1:00 PM, observation revealed one (1) of seven (7) required exits to be inaccessible. The South Exit near helicopter pad lacked an all weather surface leading to the public way.

The maintenance director was notified during the survey and in the exit conference.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This Standard is not met as evidenced by:

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. These deficient practice had the potential of affecting one (1) of three (3) smoke compartments.


Findings include:

On 1/5/16 at 11:50 AM, observation revealed no emergency strobe light and horn system were installed on the A Hall of the Behavioral Health Unit of the facility.

The maintenance director was notified during the survey and in the exit conference.

This standard is not met as evidenced by:

Based on observations, the facility failed to conduct the required test of the sprinkler system as required by NFPA 25 section 9.7.5. This deficiency had potential to affect the entire facility on the day of the survey.

Findings Include:

On 1/5/16 at 1:00 PM, the facility was unable to provide records/documentation for the the quarterly and annual testing of the automatic sprinkler system.

The maintenance director was notified during the survey and in the exit conference.

This standard is not met as evidenced by:

Based on observations, the facility failed to conduct the required test of the hood kitchen system as required by NFPA 96. This deficiency had potential to affect the entire facility on the day of the survey.

Findings Include:

On 1/5/16 at 12:45 PM, the facility was unable to provide the last two (2) inspections for the the testing and maintenance of the Kitchen commercial hood system and components.

The maintenance director was notified during the survey and in the exit conference.

NFPA 18.3.2.6 Cooking Facilities.
Cooking facilities shall be protected in accordance with 9.2.3.

NFPA 9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NNFPA 96 8-2 Inspection.
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

This Standard is not met as evidenced by:

Based on record review, the facility failed to maintain the generator as required in NFPA 110 section 6.4.2. This deficiency had potential to affect the entire facility on the day of the survey.

Findings include:

1. On 1/5/16 at 1:05 PM, the facility was unable to provide documentation of the monthly load testing and weekly inspections of the generator.

The maintenance director was notified during the survey and in the exit conference.

NFPA 110, 6-4.2 required generator to be exercised under load for 30 minutes monthly.