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Based on observation, the facility failed to properly maintain exit egress in accordance to NFPA 101 sections 19.2.1 and 7.1.10.1. These deficiencies practice affected two (2) of 15 exits in the Main Campus building of the facility.

Findings include:

On January 24, 2017 at 10:55 AM, observation revealed blocked exit egress in the following locations at the Main Campus of the facility:

1) The Administration stairwell exit was obstructed by wooden pallets
2) The Kitchen exit was obstructed by food carts and storage of boxes

Based on observation, the facility failed to provide clear and unobstructed corridors in accordance to NFPA 101 sections 19.2.3.4 and 19.2.3.5. These deficiencies practice affected one (1) of 15 exits in the Main Campus building of the facility.

Findings include:

On January 24, 2017 at 11:15 AM, observation revealed three (3) gurneys and two (2) patient beds obstructing the Emergency Room exit corridor of the Main Campus facility.

Based on observation, the facility failed to properly arrange exit discharge in accordance to NFPA 101 sections 19.2.7, 7.7 and S&C letter 05-38. These deficiencies practice affected three (3) of 10 exits in the West Campus building of the facility.

Findings include:

On January 24, 2017 at 9:30 AM, observation revealed three (3) exit discharges were not leading all-weather surfaces to the public way at the West Campus of the facility. The following exit discharges were East exit from the APS Unit, South Hall exit in Senior Care, and West Hall exit to the courtyard.

Based on observations, the facility failed to properly install fire extinguishers in accordance NFPA 101 section 19.3.5.12 and NFPA 10 section 6.1.3.8.1. These deficient practices have the potential of affecting four (4) of four (4) smoke compartments in the West Campus facility on the day of survey.

Findings Include:
On January 24, 2017 at 11:00 AM, observation revealed all the fire extinguishers in the West Campus Building were installed and mounted 6 feet from the floor of the facility.

It was stated to the maintenance director the maximum height for fire extinguishers is five feet from the floor of the facility.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with NFPA 101 19.3.7.3, 8.5, 8.5.6. These deficient practices have the potential of affecting four (4) of four (4) smoke compartments in the West Campus facility on the day of survey.

On January 24, 2017 at 10:50 AM, observations revealed open and unsealed penetrations in the all four (4) smoke barrier walls in the West Campus facility.