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Based on observations the facility failed to provide the required readily accessible access to exits marked by approved, readily visible signs in all cases where the exit or way to reach apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit" in existing facility in accordance to NFPA 101 sections 7.10, 18.2.10.1, 19.2.10.1. The deficient practice affected five (5) of 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

While inspecting the exits on 06/09/15 at 11:15 a.m. observation revealed the following the central service stairwell doors could be mistaken for an exit and did not have a signal reading "NO EXIT":

1. Central stairwell service door on 5th Floor in Compartment 5.2

2. Central stairwell service door on 4th Floor in Compartment 4.2

3. Central stairwell service door on 3rd Floor in Compartment 3.5

4. Central stairwell service door on 2nd Floor in Compartment 2.5

5. Central stairwell service door on 1st Floor in Compartment 1.5

The central stairwell service doors were constructed with a glass vision panel and the stairs were visible through the glass.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 06/09/15.

Based on observation, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. The deficient practice affected two (2) of 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

Observation during the building inspection tour on 06/09/15 at 1:30 p.m. revealed the Treatment Room 8 on the 1st Floor in Smoke Compartment 1.1 was being used as storage of medical equipment. The door of Treatment Room 8 also lacked self closing device.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 06/09/15.

Based on document review, the facility failed to provide the required fire drill documentation to confirm fire drills had been conducted one per shift per quarter for the last 12 months for three (3) of three (3) shifts (7 a.m.-3 p.m., 3 p.m.-11 p.m., 11 p.m.- 7 a.m.) in accordance to NFPA 101 chapter 18.7.1.2, 19.7.1.2.The deficient practice had potential to affect all 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

While reviewing fire drill documentation on 06/09/15 at 10:30 a.m., the facility did not provide the documentation for fire dills conducted on the 2nd shift in the months of June 2014 to September 2014.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 06/09/15.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. NFPA 72 Section 1-5.6. The deficient practice affected four (4) of 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

On 06/09/15 at 12:30 p.m., observation revealed the following the emergency strobe lights were not synchronized in the following areas of the facility:

1. 2nd Floor Smoke Compartments 2.2, 2.4, and 2.5
2. 4th Floor Smoke Compartment 4.2

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 06/09/15.

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building as directed in NFPA 13 section 5-13.8.1. The deficient practice had potential to affect all 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

On 06/09/15 at 11:30 a.m., observation revealed the the sprinkler head in Stairwell G, near Room 310, in Smoke Compartment 3.1, was obstructed by a ceiling tile.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 06/09/15.

Based on observations, the facility failed to install alcohol based hand rub in approved areas in accordance to NFPA 18.3.2.7 The deficient practice affected one (1) of 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

Observation during the building inspection tour on 06/09/15 at 11:30 a.m. revealed an alcohol based hand sanitizer dispenser was mounted directly above the light switch behind the 3rd Floor Nurse Station in Smoke Compartment 3.5. The light switch is considered an ignition source.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 06/09/15.

Based on observations the facility failed to provide the required readily accessible access to exits marked by approved, readily visible signs in all cases where the exit or way to reach apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit" in existing facility in accordance to NFPA 101 sections 7.10, 18.2.10.1, 19.2.10.1. The deficient practice affected five (5) of 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

While inspecting the exits on 06/09/15 at 11:15 a.m. observation revealed the following the central service stairwell doors could be mistaken for an exit and did not have a signal reading "NO EXIT":

1. Central stairwell service door on 5th Floor in Compartment 5.2

2. Central stairwell service door on 4th Floor in Compartment 4.2

3. Central stairwell service door on 3rd Floor in Compartment 3.5

4. Central stairwell service door on 2nd Floor in Compartment 2.5

5. Central stairwell service door on 1st Floor in Compartment 1.5

The central stairwell service doors were constructed with a glass vision panel and the stairs were visible through the glass.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 06/09/15.

Based on observation, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. The deficient practice affected two (2) of 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

Observation during the building inspection tour on 06/09/15 at 1:30 p.m. revealed the Treatment Room 8 on the 1st Floor in Smoke Compartment 1.1 was being used as storage of medical equipment. The door of Treatment Room 8 also lacked self closing device.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 06/09/15.

Based on document review, the facility failed to provide the required fire drill documentation to confirm fire drills had been conducted one per shift per quarter for the last 12 months for three (3) of three (3) shifts (7 a.m.-3 p.m., 3 p.m.-11 p.m., 11 p.m.- 7 a.m.) in accordance to NFPA 101 chapter 18.7.1.2, 19.7.1.2.The deficient practice had potential to affect all 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

While reviewing fire drill documentation on 06/09/15 at 10:30 a.m., the facility did not provide the documentation for fire dills conducted on the 2nd shift in the months of June 2014 to September 2014.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 06/09/15.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. NFPA 72 Section 1-5.6. The deficient practice affected four (4) of 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

On 06/09/15 at 12:30 p.m., observation revealed the following the emergency strobe lights were not synchronized in the following areas of the facility:

1. 2nd Floor Smoke Compartments 2.2, 2.4, and 2.5
2. 4th Floor Smoke Compartment 4.2

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 06/09/15.

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building as directed in NFPA 13 section 5-13.8.1. The deficient practice had potential to affect all 26 smoke compartments. The facility had the capacity for 153 beds with a census of 33 on the day of survey.

Findings Include:

On 06/09/15 at 11:30 a.m., observation revealed the the sprinkler head in Stairwell G, near Room 310, in Smoke Compartment 3.1, was obstructed by a ceiling tile.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 06/09/15.