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Based upon observation and staff interview, exit signs are not placed appropriately to identify available exit paths. Failure to correctly identify exit paths can result in occupants not being able to identify and reach available exit paths during a fire/smoke emergency.

Findings include:

On October 4, 2022, at 2:00 pm while in the company of the DOP, it was observed that exit signage was not provided to identify the means of egress at the 2N hallway near Fire Stair door to comply with 19.2.10.1 and 7.10.

Based upon observation and staff interview, the facility failed to correctly install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and lack of response to the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

On October 4, 2022, at 1:20 pm while in the company of the DOP, it was observed that the Elevator machine room lacks a compliant means to automatically disconnect the main power supply to elevators prior to the application of water due to activation of the fire sprinkler system. At the elevator machine room, heat detector is not installed within 2 feet of the sprinkler head for elevator shutdown. This does not comply with 19.5.3 ANSI/ASME A17.1, Section 102.2(c)(3) and NFPA 72-2010, 21.4.2.