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Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 50% of the residents and staff. This deficient practice has the potential of affecting 2 of 6 smoke compartments.

Findings include:

While inspecting smoke barrier walls on April 21, 2015 at 11:30 a.m., observation revealed the smoke barrier wall in Dining Room was not completely constructed to roof deck and the smoke barrier also had an incomplete wall space was 24" tall and 75% open the length of wall. The DON and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to properly protect hazardous areas. This deficient practice has the potential of affecting 25% of the residents and staff.

Findings include:

On 4/21/15 at 12:35 p.m., observation revealed that the Soiled Linen Room in ICU had open penetrations and did not provide the required 1 hour fire protection rating for hazardous area above ceiling. The DON and maintenance director were notified during the survey and in the exit conference.

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, 7.1.10.1. and all states letter Ref: S&C -07-05. This condition had the potential to affect 100% of the residents and staff.

Findings Include:

On April 21, 2015 at 1:00 p.m., observation revealed 1 of the 7 required exits to be inaccessible. The exit from the 100 hallway leading to new hospital addition lacked access to required exit. This required exit was inaccessible by locked corridor doors and unmovable obstructions (new addition's building construction materials) in hall leading to required exit.

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.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency other than corridors or lobbies.

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building. This deficiency affected one (1) of three (5)
smoke compartments and all residents in the facility on the day of survey.

Findings include:

On April 21, 2015 at 11:45 a.m., observation revealed that the freezer in the kitchen lacked the required sprinkler head with connection to the supervised automatic sprinkler system. The DON and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 50% of the residents and staff. This deficient practice has the potential of affecting 2 of 6 smoke compartments.

Findings include:

While inspecting smoke barrier walls on April 21, 2015 at 11:30 a.m., observation revealed the smoke barrier wall in Dining Room was not completely constructed to roof deck and the smoke barrier also had an incomplete wall space was 24" tall and 75% open the length of wall. The DON and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to properly protect hazardous areas. This deficient practice has the potential of affecting 25% of the residents and staff.

Findings include:

On 4/21/15 at 12:35 p.m., observation revealed that the Soiled Linen Room in ICU had open penetrations and did not provide the required 1 hour fire protection rating for hazardous area above ceiling. The DON and maintenance director were notified during the survey and in the exit conference.

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, 7.1.10.1. and all states letter Ref: S&C -07-05. This condition had the potential to affect 100% of the residents and staff.

Findings Include:

On April 21, 2015 at 1:00 p.m., observation revealed 1 of the 7 required exits to be inaccessible. The exit from the 100 hallway leading to new hospital addition lacked access to required exit. This required exit was inaccessible by locked corridor doors and unmovable obstructions (new addition's building construction materials) in hall leading to required exit.

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.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency other than corridors or lobbies.

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building. This deficiency affected one (1) of three (5)
smoke compartments and all residents in the facility on the day of survey.

Findings include:

On April 21, 2015 at 11:45 a.m., observation revealed that the freezer in the kitchen lacked the required sprinkler head with connection to the supervised automatic sprinkler system. The DON and maintenance director were notified during the survey and in the exit conference.