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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. The deficient practice affected two (2) of three (3) smoke compartments.

Findings Include:

On 8/19/15 at 10:30 a.m., observation revealed two (2) of (8) hospital exit discharge were to be inaccessible in the following areas of the facility:

1. Exit near North Station One Hall Wing
2. Exit in the Outpatient Services West Wing

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 08/19/15.

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.

This Standard is not met as evidenced by:

Based on observations, the facility failed to provide a complete manual fire alarm system as directed by NFPA 72 Section 2-1.3.4. The deficient practice affected one (1) of three (3) smoke compartments.

Findings include:

On 08/19/15 at 10:50 a.m., observation revealed the manual pull station near Laundry Room exit door failed to have the proper connection to the fire alarm system. Manual pull stations shall be provided on each initiating device for the express purpose of connecting into the fire alarm system.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 08/19/15.

This standard is not met as evidenced by:

Based on observation, the facility failed to properly mount all fire extinguishers in accordance NFPA 10 section 1.6.10. This condition had the potential to affect the entire facility at the time of the survey.

Findings Include:

On 8/19/15 at 10:15 a.m., observation revealed all fire extinguishers were mounted 8 feet above the floor level in the Northwest and Northeast Wings of the facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 08/19/15.

NFPA 10 section 1.6.10

Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

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. The deficient practice affected two (2) of three (3) smoke compartments.

Findings Include:

On 8/19/15 at 10:30 a.m., observation revealed two (2) of (8) hospital exit discharge were to be inaccessible in the following areas of the facility:

1. Exit near North Station One Hall Wing
2. Exit in the Outpatient Services West Wing

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 08/19/15.

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.

This Standard is not met as evidenced by:

Based on observations, the facility failed to provide a complete manual fire alarm system as directed by NFPA 72 Section 2-1.3.4. The deficient practice affected one (1) of three (3) smoke compartments.

Findings include:

On 08/19/15 at 10:50 a.m., observation revealed the manual pull station near Laundry Room exit door failed to have the proper connection to the fire alarm system. Manual pull stations shall be provided on each initiating device for the express purpose of connecting into the fire alarm system.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 08/19/15.

This standard is not met as evidenced by:

Based on observation, the facility failed to properly mount all fire extinguishers in accordance NFPA 10 section 1.6.10. This condition had the potential to affect the entire facility at the time of the survey.

Findings Include:

On 8/19/15 at 10:15 a.m., observation revealed all fire extinguishers were mounted 8 feet above the floor level in the Northwest and Northeast Wings of the facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on the exit interview on 08/19/15.

NFPA 10 section 1.6.10

Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).