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Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code 19.2 and 7.1.10.1.
This was evidenced by:
1.Storage Door 6604 is greater than 7" from wall when fully open. Only opens 90 degree. Needs to fully open.

The Maintenance Director acknowledged the means of egress deficiency during the tour of the facility.

This deficient practice could has the potential to affect all staff, visitors, and residents ' through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained delayed exit doors in accordance with Life Safety Code Section 7.2.1.6.2 and 19.2.2.2.4 This was evidenced by the following:

1. 1st floor -Door 1665A did not release on water flow activation.
2. Door 7611G - nuisance alarm - Central Tower (Corrected during survey)
3. Door 7649F - nuisance alarm – Central Tower (Corrected during survey)
4. Door 1608a - nuisance alarm – Central Tower
5. "Alarm verification in progress" upon smoke detector activation door 7603b didn't close upon alarm. (Corrected during survey)
6. Door 7649F didn't release upon smoke detector activation. (Corrected during survey)

The Maintenance Director acknowledged the door deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing an excessive time to exit from the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained egress doors in accordance with Life Safety Code Section 19.2.2.2.7 This was evidenced by the following:
1. 4th floor - Staff elevator lobby fire doors not latching. (Corrected during survey)
2. Fire door will not latch in solid utility A1343SU. 1st floor. (Corrected during survey)
The Maintenance Director acknowledge egress door deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing the spread of fire and smoke throughout the smoke compartments.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the course of the survey conducted on June 5, 2017, it was determined the facility failed to maintain the stair enclosure in accordance with NFPA 101, 39.2.2.3, 7.2.2 and 7.1. The following evidenced this:

During the walk-through with the Maintenance Personnel;
A. Unable to verify fire-rating of stairway on 3rd floor, stair #3, UL label was painted over.

The deficiency has the potential to affect occupants, who might include staff, patients and visitors within 1 of 4 stair enclosures; item was discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain a second means egress from a smoke compartment in accordance with Life Safety Code Section 19.2.5.2. This was evidenced by the following:
1. 4th and 5th floors contained construction plastic covering both sides of the smoke barrier door preventing a second means of egress from the smoke compartment creating a dead-end corridor. (Corrected immediately during survey)

The Maintenance Director acknowledged the 2nd means of egress deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing a excessive time to exit from the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain exit signs in accordance with Life Safety Code Section 19.2.10 This was evidenced by the following:
1. Room 0634 exit light out in North Tower basement. (Corrected during survey)
2. Exit sign was covered at 2nd exit from smoke compartment. (Corrected during survey)

The Maintenance Director acknowledged the exit signage deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained vertical openings in accordance with Life Safety Code Section 19.3.1 This was evidenced by the following:
1. Room 168A above ceiling penetration, Central Tower 1st floor.
2. Room 0541A above ceiling penetration, Central Tower 1st floor. (Corrected during survey)
3. Room 3590 ceiling penetration, Central Tower 3rd floor.
4. Room 4590 ceiling penetration.

The Maintenance Director acknowledged the exit signage deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain hazardous area doors in accordance with Life Safety Code Section 19.3.2.1. This was evidenced by the following:
1. Fire door will not latch in room soiled linen room BG224SL. Basement. (Corrected during survey)

The Maintenance Director acknowledge door discrepancy during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing fire or smoke to develop throughout the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation during the survey, conducted on June 5, 2017, it was determined the facility failed to install and maintain the fire alarm system in accordance with NFPA 101, section 39.3.4 and 9.6, including NFPA 72 National Fire Alarm Code. The following evidenced this:

During the walk through with the Maintenance Personnel;
A. Suite 315, smoke detectors are located within 3 feet of a return or supply diffuser which could prevent operation of the detector by rooms 315.04 and 315.11.

The fire alarm deficiency has the potential to affect all room occupants, who might include staff, patients and visitors within the suite; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with Life Safety Code 9.7.7 and NFPA 25 This was evidenced by the following:
1. Multiple exit delayed egress doors did not open upon activation of smoke detectors and water flow alarms.

The Maintenance Director acknowledged the fire alarm deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintained the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) 13 and Life Safety Code Section 19.3.5
This was evidenced by the following:
4th floor - Sprinkler heads closer than 6' to each other in room A4112

The Maintenance Director acknowledge sprinkler deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing fire to develop throughout the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, conducted on June 6, 2017, it was determined the facility failed to install the automatic fire sprinkler system in accordance with NFPA 101, section 19.3.5, 19.3.5.1, 9.7 including NFPA 25. The following evidenced this:

During the walk through with the maintenance personnel;
A. Storage is too high in clean linen closet. Maintain minimum clearance of 18 inches below all sprinkler deflectors, NFPA 25, section 5.2.1.2

The fire sprinkler deficiencies has the potential to affect all room occupants, who might include staff, patients and visitors; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain a portable fire extinguisher as required by NFPA 10 Chapter 4. This was evidence by the following:

1. Fire extinguisher near room 3 had a pressure gauge that was below the
green safe level. (Corrected during the survey)

The Maintenance Director acknowledged this deficiency during the survey.

This deficiency could affect all visitors and stall in the event of fire.

This was discussed during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain automatic closing doors in accordance with Life Safety Code Section 19.3.6.3. This was evidenced by the following:
1. Automatic closing doors at locations 8601, 7600E, and 3620 do not positively latch closed. (Corrected during survey)

The Maintenance Director acknowledged the door deficiencies during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain smoke barriers in accordance with the Life Safety Code 19.3.7.3.
1. 3 penetrations above ceiling in room A2120. 2nd floor. (Corrected during survey)
2. Penetration above ceiling in solid utility A1343SU on SW wall. 1st floor. (Corrected during survey)
3. Penetration above ceiling on southeast wall with chilled and heated water piping in public elevator lobby. 1st floor. A1200. (Corrected during survey)
4. 1 penetration on south wall in biohazard room BG221. Basement. (Corrected during survey)

The Maintenance Director acknowledged the smoke barrier deficiencies during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment by allowing fire or smoke to develop throughout the smoke compartment.

These deficiencies were discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on observation and staff interview during the course of the survey conducted on June 5, 2017, it was determined the facility failed to maintain power strips and extension cords in accordance with NFPA 70, National Electric Code. The following evidenced this:

During the walk through of the facility with the Maintenance Personnel;
A. Suite 230 - Intake office contained a light duty power strip plugged into a light duty power strip with the potential to overload the circuit. Both power strips were rearranged and plugged directly into the wall outlet during the survey.

The electrical deficiency has the potential to affect all room occupants, who might include staff and visitors; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the electrical junction box in accordance with Life Safety Code Section 19.5.2.1 This was evidenced by the following:
1. Room A3325 - open lighting junction box. 3rd floor. (Corrected during survey)

The Maintenance Director acknowledged the electrical deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

This deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.

Based on record review and staff interview during the survey, conducted June 5, 2017, it was determined the facility failed to conduct fire drills in accordance with NFPA 101, 21.7.1. The following evidenced this:

During review of the facility records with the Maintenance Personnel;
A. Simulated fire drills were conducted once per quarter, reports indicate there was no activation of any audible notification devices to alert staff in maintaining the awareness of the alarm signals. Audible signal are required for every fire drill performed.

The fire drill deficiency has the potential to affect all occupants, who might include staff, patients and visitors within 2 of 2 smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain electrical power cords in accordance with NFPA 99, and Life Safety Code Section 10.2.3.6. This was evidenced by the following:

1. Refrigerator is plugged into a power strip corridor near south mechanical room. (Corrected during survey)

The Maintenance Director acknowledged the electrical power cord deficiency during the tour of the facility.

This deficient practice could affect all residents and staff through-out the smoke compartment.

The deficiency was discussed with the administrative staff and maintenance director during the exit conference on June 8, 2017.