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Based on observation and interview, the facility failed to provide a building construction type permitted for a three story building with a complete automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.1.6.1, and Table 19.1.6.1

Findings include:

On 02/13/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed a structural I-beam missing the one hour rated sprayed on fire protection on the bottom of the beam and the side facing the one hour fire rated smoke barrier. This I-beam is located on the second floor above the ceiling at the entrance to the Boys RTC Unit near the smoke barrier.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain the means of egress of all obstructions or impediments to the full instant use in the case of fire or other emergency per the requirements of:

2012 NFPA 101, 19.2.1, 7.2.1.5.1 and 7.2.1.5.3

Findings include:

On 02/13/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed a padlock on the IT/Telephone Room door on the second floor near Acute Adolescent North Wing.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to maintain the Alcohol Based Hand Rub Dispensers (ABHRs) per the requirements of:

2012 NFPA 101, 19.3.2.6 (11) f

This deficiency could affect all residents.

Findings include:

On 02/13/2018, during a tour of the facility from 9:15 am to 5:00 pm, the facility failed to provide documentation on the testing in accordance with the manufacturer's care and use instructions each time a new refill is installed.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to provide interior wall finishes per the requirements of:

2012 NFPA 101, 19.3.3.1, 19.3.3.2, and 10.2

This deficiency could affect 1 of 8 smoke compartments.

Findings include:

On 02/13/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed carpet applied to all four walls of the Isolation Room near the Nurses' Station on the second floor. The facility failed to provide documentation on the flame spread rating for the vertically applied carpet used as interior wall finish.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to provide documentation on the testing and inspection of the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1 and 9.7.5
2011 NFPA 25, 5.2.4.1

This deficiency could affect all residents.

Findings include:

On 02/13/2018, during a tour of the facility from 9:15 am to 5:00 pm, the facility failed to provide documentation on monthly inspections on the wet sprinkler riser gauges.

A member of the maintenance staff was present when the deficiency was found.

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Based on observation and interview, the facility failed to maintain a corridor wall to limit the transfer of smoke per the requirements of:

2012 NFPA 101, 19.3.6.2.3

This deficiency could affect 1 of 8 smoke compartments.

Findings include:

On 02/13/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed several approximately one inch unsealed penetrations in the corridor wall at the IT/Telephone Room on the 2nd Floor at Acute Adolescent North Wing.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain a corridor door per the requirements of:

2012 NFPA 101, 19.3.6.3.5
42 CFR 482.41 (b) (1) (ii)

This deficiency could affect 2 residents.

Findings include:

On 02/13/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed room 316's corridor door failed to positive latch in the frame.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain a smoke barrier 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, and 8.5.6.2

This deficiency could affect 2 of 8 smoke compartments.

Findings include:

On 02/13/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed an approximately three inch unsealed penetration of several conduits above the ceiling in the smoke barrier near the Girls Day Room on the second floor.

A member of the maintenance staff was present when this deficiency was identified.

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