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Based on observation, the facility failed to provide an exit discharge with a hard-packed all-weather travel surface.

The deficiency affected 1 of 2 smoke compartments, staff, and 4 of 8 patients.

The findings included:

Observation with the Chief Safety Officer on 6/7/2021 at 11:49 AM, revealed the emergency exit discharge, from the women's hallway, is not provided with a hard- packed all-weather travel surface leading to a public way.
NFPA 101, 2012 Edition 19.2.7, 7.7.1*, 7.1.6.4, S&C-05-38

The Chief Safety Officer was present when the deficiency was identified and acknowledged by Administration during the exit conference on 6/7/2021.

Based on observation, the facility failed to provide exit signs to indicate the direction of egress.

The deficiency affected 1 of 2 smoke compartments, staff, and 4 of 8 patients.

The findings included:

Observation with the Chief Safety Officer on 6/7/2021 at 11:55 AM, revealed the interior courtyard failed to have exit signage indicating the direction of egress.
NFPA 101, 2012 Edition 19.2.10.1, 7.10, 7.10.1.2, 7.10.1.2.1*

The Chief Safety Officer was present when the deficiency was identified and acknowledged by Administration during the exit conference on 6/7/2021.

Based on observation, the facility failed to protect hazardous areas.

The deficiency affected 1 of 2 smoke compartments, staff, and 4 of 8 patients.

Findings include:

Observation with the Chief Safety Officer on 6/7/2021 at 11:50 AM, revealed the storage room door, on the women's hallway, was not self-closing or automatic closing. The room is being used to store combustible materials.
NFPA 101, 2012 Edition 19.3.2, 19.3.2.1.3, 19.3.2.1.5 (7)

The Chief Safety Officer was present when the deficiency was identified and acknowledged by Administration during the exit conference on 6/7/2021.