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Based on observation and interview, the provider failed to arrange exit discharge as required due to abrupt changes in elevation greater than 1/4 inch found at an exit to the public way (main entrance). Findings include:

1. Observation at 9:30 a.m. on 7/31/19 revealed the main entrance/exit discharge did not meet change in elevation requirements. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 inch. The main entrance had a 9/16 inch drop and was painted yellow as a warning to pedestrians. Interview with the maintenance supervisor at the time of the observation confirmed that finding.

Ref: 2012 NFPA 101 Section 19.2.7, 7.7.4, 7.1.6.2

Failure to arrange exit discharge as required increases the risk of death or injury due to fire.

The deficiency affected one of three exit discharges.

Based on observation and interview, the provider failed to maintain one of two hazardous areas (ambulance garage) as required (unsealed penetrations). Findings include:

1. Observation beginning at 11:00 a.m. on 7/31/19 revealed five unsealed penetrations of the south wall of the electrical room-222 by a bar joist, two 1-1/4 inch electrical conduits, and two 2 inch insulated water pipes. The south wall of the water service room-221 had two 2 inch pvc drain lines through the two-hour, fire-rated wall to the emergency room department that were unsealed. The penetration openings must be sealed with an approved fire-stop material such as intumescing fire caulk. Interview with the maintenance supervisor at the times of the observations confirmed those findings.

The deficiency affected one of numerous requirements for hazardous rooms.