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Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

- During the morning hours of 9/11/12 while touring the facility, it was observed that the non-sprinklered Elevator Mechanical Room located on the second floor of the Draper Building has a non-rated door and is lacking a self closing device.

This was acknowledged by the Administrative staff during the exit conference.

Based on observation, the facility failed to ensure compliance with Means of Egress Reliability. Section No. 7.1.10.1 states, Means of Egress shall be continuously maintained free of all obstructions or impediments to full and instant use in the case of fire or other emergency. Section No. 7.1.10.2.1 states, no furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 9/11/12 & 9/12/12 while touring the facility, it was observed that corridors throughout the Lorusso building are cluttered by equipment such as: computers on wheels and medical supply carts, thereby infringing on the full instant use of corridors as well as obstructing access to exits. This was confirmed by the physical plant director.

This was acknowledged by the Administrative staff during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

- During the morning hours of 9/11/12 while touring the facility, it was observed that the non-sprinklered Elevator Mechanical Room located on the second floor of the Draper Building has a non-rated door and is lacking a self closing device.

This was acknowledged by the Administrative staff during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted utilizing the various times & conditions as required.

THE FINDINGS INCLUDE:

- During the morning hours of 8/11/12 while performing the record review process, it was observed that the fire drills are not conducted as required. The fire drills for the 2nd (3:00 P.M.-11:00P.M.) & 3rd (11:00 P.M.-7:00 A.M.) shifts are documented as occurring at the following times:

2nd Shift: 8/7/12 @ 3:35 P.M.; 6/18/12 @ 3:25 P.M.; 4/24/12 @ 3:07 P.M.; 2/28/12 @ 3:20 P.M.; 12/21/11 @ 3:45 P.M.; 10/26/11 @ 3:45 P.M. and 9/26/11 @ 4:20 P.M.

3rd Shift: 8/29/12 @ 5:20 A.M.; 7/25/12 @ 5:30 A.M.; 4/25/12 @ 5:25 A.M.; 3/28/12 @ 4:15 A.M.; 1/25/12 @ 4:35 A.M.; 12/21/11 @ 5:20 A.M.; and 11/23/11 @ 4:15 A.M.

The following deficiencies were noted:

1) 2nd Shift (3:00 P.M. - 11:00 P.M.) Seven of seven fire drills conducted on the 2nd shift were held between 3:07 P.M. & 4:20 P.M. The entire 8-hour shift period is not being utilized to conduct the fire drills.

2) 3rd Shift (11:00 P.M.-7:00 A.M.): Seven of seven fire drills conducted on the 3rd shift were held between 4:15 A.M. & 5:30 A.M. The entire 8-hour shift period is not being utilized to conduct the fire drills.

This was acknowledged by the Administrative staff during the exit conference.

Based on observation, the facility failed to ensure compliance with Means of Egress Reliability. Section No. 7.1.10.1 states, Means of Egress shall be continuously maintained free of all obstructions or impediments to full and instant use in the case of fire or other emergency. Section No. 7.1.10.2.1 states, no furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

THE FINDINGS INCLUDE:

- During the morning and afternoon hours of 9/11/12 & 9/12/12 while touring the facility, it was observed that corridors throughout the Lorusso building are cluttered by equipment such as: computers on wheels and medical supply carts, thereby infringing on the full instant use of corridors as well as obstructing access to exits. This was confirmed by the physical plant director.

This was acknowledged by the Administrative staff during the exit conference.