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Based on observation and record review, the facility failed to provide smoke compartments that do not exceed 22,500 square feet for 4 of 32 smoke compartments in the facility. This could potentially affect 292 patients in 32 of 32 smoke compartments in the event of a smoke or fire emergency requiring a shelter in place by the facility.

Findings: During a tour of the facility between 4/15/13 and 4/18/13, the smoke zones 1B on the first floor, and smoke zones 2C, 2D, and 2E were noted to be in excess of 22,500 square feet.

NOTE: There is a favorable FSES on this deficiency.

Based on observation and record review, the facility failed to provide stairways that are enclosed with construction having a fire resentance rating of at least one hour for 1 stairwell in 1 of 32 smoke compartments. This could potentially affect 292 patients in the event of a fire or smoke emergency which caused a complete evacuation of the facility.

Findings: During a tour of the facility between 4/15/13 and 4/18/13, the exit stair 4B was observed to have several chiller and water lines penetrating through it and did not serve the stairwell.

NOTE: Review of records revealed the facility had an FSES conducted on it for this deficiency.

Based on observation and record review, the facility failed to provide exit access so that the exits and exit corridors are readily accessible at all times for 32 of 32 smoke compartments. This could potentially affect 292 of 292 patients in 32 of 32 smoke compartments in the event of a smoke or fire emergency that require total evacuation of the facility.

Findings: During a tour of the facility between 4/15/13 and 4/18/13, the Ceiling heights throughout were observed to be 7 feet 2 inches with projections less than 6 feet 8 inches.

NOTE: There was a favorable FSES conducted on this facility to offset this deficiency.

Based on observation and record review, the facility failed to provide smoke compartments that do not exceed 22,500 square feet for 4 of 32 smoke compartments in the facility. This could potentially affect 292 patients in 32 of 32 smoke compartments in the event of a smoke or fire emergency requiring a shelter in place by the facility.

Findings: During a tour of the facility between 4/15/13 and 4/18/13, the smoke zones 1B on the first floor, and smoke zones 2C, 2D, and 2E were noted to be in excess of 22,500 square feet.

NOTE: There is a favorable FSES on this deficiency.

Based on observation and record review, the facility failed to provide stairways that are enclosed with construction having a fire resentance rating of at least one hour for 1 stairwell in 1 of 32 smoke compartments. This could potentially affect 292 patients in the event of a fire or smoke emergency which caused a complete evacuation of the facility.

Findings: During a tour of the facility between 4/15/13 and 4/18/13, the exit stair 4B was observed to have several chiller and water lines penetrating through it and did not serve the stairwell.

NOTE: Review of records revealed the facility had an FSES conducted on it for this deficiency.

Based on observation and record review, the facility failed to provide exit access so that the exits and exit corridors are readily accessible at all times for 32 of 32 smoke compartments. This could potentially affect 292 of 292 patients in 32 of 32 smoke compartments in the event of a smoke or fire emergency that require total evacuation of the facility.

Findings: During a tour of the facility between 4/15/13 and 4/18/13, the Ceiling heights throughout were observed to be 7 feet 2 inches with projections less than 6 feet 8 inches.

NOTE: There was a favorable FSES conducted on this facility to offset this deficiency.