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Based on observation and staff interview, access exits was not marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to occupants.

Findings included:

No exit signs were provided in the rehab area, waiting area of the rehab and occupational therapy and the occupational therapy areas. In the event of fire or smoking, staff could not find their way out of those areas.

Based on on observation the facility did not ensure that all required smoke barrier walls in the hospital were maintained as required.

Findings:

Penetrations were noted around four (4) conduits in the electric equipment room 834 that had one hour fire separation.

Based on observation and interview the hospital did not ensure that the required fire alarm system was maintained in accordance with the requirements of NFPA 72.

Findings:

Review of the fire alarm testing records on the afternoon of 9/28/2011 revealed that many smoke detectors were not tested during two consecutive tests performed in 2011, specifically, on 1/18/2011 and 6/20/2011. Examples of non tested smoke detectors included smoke detectors # 2103055, 2103056, 2103057, 210305859, 2103060, 2103061, 2103062, 210306364, 2103065, 2103066, 2103067, 2103068, 2103069, 2103070, 2103071, 2103072, 2103073, 2103074.

Another set of smoke detectors were not tested during the two semiannual tests of 2011, included Smoke detectors # 0602053, 0602054, 0602055, 0602056, 0602057, 0602058, 0602059, 0602060, 0602061, 0602062, 0602063, 0602064, 0602065, 060266, 0602067.

Interview with the Director of Safety, revealed that the facility had a fire in the energy center on December 22, 2010, and that this area is under construction. When asked, the safety director said the large number of the damaged smoke detectors was because the electric wires of many detectors were damaged by the fire, and that the affected locations are without smoke detector coverage until now.

On the afternoon of 9/29/2011, the following was observed during a tour of the Rehabilitation Suite on the 3rd floor of CHC Building:
No fire strobes were provided in the patient bathrooms, the waiting area, or the occupational therapy area of the Rehabilitation unit.

Based on observation and staff interview, access exits was not marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to occupants.

Findings included:

No exit signs were provided in the rehab area, waiting area of the rehab and occupational therapy and the occupational therapy areas. In the event of fire or smoking, staff could not find their way out of those areas.

Based on on observation the facility did not ensure that all required smoke barrier walls in the hospital were maintained as required.

Findings:

Penetrations were noted around four (4) conduits in the electric equipment room 834 that had one hour fire separation.

Based on observation and interview the hospital did not ensure that the required fire alarm system was maintained in accordance with the requirements of NFPA 72.

Findings:

Review of the fire alarm testing records on the afternoon of 9/28/2011 revealed that many smoke detectors were not tested during two consecutive tests performed in 2011, specifically, on 1/18/2011 and 6/20/2011. Examples of non tested smoke detectors included smoke detectors # 2103055, 2103056, 2103057, 210305859, 2103060, 2103061, 2103062, 210306364, 2103065, 2103066, 2103067, 2103068, 2103069, 2103070, 2103071, 2103072, 2103073, 2103074.

Another set of smoke detectors were not tested during the two semiannual tests of 2011, included Smoke detectors # 0602053, 0602054, 0602055, 0602056, 0602057, 0602058, 0602059, 0602060, 0602061, 0602062, 0602063, 0602064, 0602065, 060266, 0602067.

Interview with the Director of Safety, revealed that the facility had a fire in the energy center on December 22, 2010, and that this area is under construction. When asked, the safety director said the large number of the damaged smoke detectors was because the electric wires of many detectors were damaged by the fire, and that the affected locations are without smoke detector coverage until now.

On the afternoon of 9/29/2011, the following was observed during a tour of the Rehabilitation Suite on the 3rd floor of CHC Building:
No fire strobes were provided in the patient bathrooms, the waiting area, or the occupational therapy area of the Rehabilitation unit.