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Based on observation, the facility failed to provide partitions that resist the passage of smoke in a partial sprinkled building.

Findings include:

While inspecting the corridor walls on June 4, 2014 and June 5, 2014, the surveyor and maintenance supervisor observed open penetrations in the following areas:

- Above the Soiled Utility Room on 3rd Floor near Room 35 (West Campus)
- Near Geriatrics Unit and Elevator Shaft #3 (West Campus)
- Near Geriatrics Unit and Recreation Room (West Campus)
- Near the nursing station in the GI Lab (West Campus)

This deficient practice affected 4 of 16 smoke compartments in the West Campus facility.
The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide shaft partitions that have a fire resistance rating of at least one hour.

Findings include:

While inspecting vertical openings on June 4, 2014 and June 5, 2014, the surveyor and maintenance supervisor observed deficient items in the following vertical shafts:

1. Elevator shaft near Maternal Child Labor had open penetrations on the wall of the vertical shafts 4th Floor. (Main Campus)

The maintenance supervisor and the administrator were notified during the exit conference.
These deficient practices have the potential of affecting the entire facility.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect the entire facility.

Finding include:

While inspecting smoke barrier walls on June 4, 2014 and June 5, 2014 at 10:30 A.M., the maintenance supervisor and the surveyor observed the smoke barrier walls had the following unsealed penetrations in the following areas:

1. Smoke barrier wall near 400 North Wing (Main Campus)
2. Smoke barrier wall near 4th Floor Rehab Center (West Campus)
3. Smoke barrier wall near 4th Floor Observation Center (West Campus)
4. Smoke barrier wall near Room 235 (West Campus)

These deficient practices have the potential of affecting 1 of 26 smoke compartments in Main Campus and 3 of 16 smoke compartments in West Campus.
The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

While inspecting hazardous areas on June 4, 2014 and June 5, 2014 , the maintenance person and surveyor found the ceiling in the Electrical Room on the 1st Floor near Cardiovascular Services in Main Campus were incapable of resisting smoke due to numerous openings and penetrations. It was also observed that Prep/ Hold Room 12 had wheelchairs stored in the room and the door of Prep/ Hold Room 12 did not have a self closing device.

These deficient practices have the potential of affecting 1 of 26 smoke compartments in Main Campus and 1 of 16 smoke compartments in West Campus.
The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and all states letter
Ref: S&C -07-05. This condition had the potential to affect the entire Main Campus facility.

Findings include:

While inspecting the exit access on June 4, 2014 and June 5, 2014 , the maintenance person and surveyor found required exits from the North Stairwell in the Main Campus for the 1st, 2nd, 3rd, and 4th Floors to be inaccessible and not leading to the public way. It was also observed the exit near Room 7 in the Heart Hospital in the Main Campus was not leading to the public way.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observations, the facility failed to provide a complete manual fire alarm system as directed by NFPA 101 Section 9.6, NFPA 72 Section 4-4.4.2.2.

Findings include:

On June 4, 2014 and June 5, 2014, the maintenance supervisor and surveyor observed the following areas did not have fire alarm signaling device:

1. 2 East Medical Surgical Center on 2nd Floor was missing emergency horn strobes. (Main Campus)

2. The compartment between Specialty Hospital and Sleep Center on 3rd Floor was missing emergency horn strobes. (West Campus)

3. The compartment between Jenkins Clinic and Geriatric Unit on 2nd Floor was missing emergency horn strobes. (West Campus)

4. The Elevator Shaft #1 on the 4th Floor was missing a smoke detector. (West Campus)

5. The Nursing Station in the GI Lab on the 1st Floor was missing a smoke detector. (West Campus)

These deficient practices have the potential of affecting 1 of 26 smoke compartments in Main Campus and 4 of 16 smoke compartments in West Campus.
The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. This condition affected 100% of the residents and staff as all smoke compartments were affected. NFPA 72 Section 1-5.6

Findings include:

On June 4, 2014 and June 5, 2014, the maintenance supervisor and surveyor observed that all emergency strobes lights need to be synchronized in all the smoke compartments of the Main Campus Facility.

This condition had the potential to affect the entire Main Campus facility.
The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation, the facility failed to provide partitions that resist the passage of smoke in a partial sprinkled building.

Findings include:

While inspecting the corridor walls on June 4, 2014 and June 5, 2014, the surveyor and maintenance supervisor observed open penetrations in the following areas:

- Above the Soiled Utility Room on 3rd Floor near Room 35 (West Campus)
- Near Geriatrics Unit and Elevator Shaft #3 (West Campus)
- Near Geriatrics Unit and Recreation Room (West Campus)
- Near the nursing station in the GI Lab (West Campus)

This deficient practice affected 4 of 16 smoke compartments in the West Campus facility.
The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide shaft partitions that have a fire resistance rating of at least one hour.

Findings include:

While inspecting vertical openings on June 4, 2014 and June 5, 2014, the surveyor and maintenance supervisor observed deficient items in the following vertical shafts:

1. Elevator shaft near Maternal Child Labor had open penetrations on the wall of the vertical shafts 4th Floor. (Main Campus)

The maintenance supervisor and the administrator were notified during the exit conference.
These deficient practices have the potential of affecting the entire facility.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect the entire facility.

Finding include:

While inspecting smoke barrier walls on June 4, 2014 and June 5, 2014 at 10:30 A.M., the maintenance supervisor and the surveyor observed the smoke barrier walls had the following unsealed penetrations in the following areas:

1. Smoke barrier wall near 400 North Wing (Main Campus)
2. Smoke barrier wall near 4th Floor Rehab Center (West Campus)
3. Smoke barrier wall near 4th Floor Observation Center (West Campus)
4. Smoke barrier wall near Room 235 (West Campus)

These deficient practices have the potential of affecting 1 of 26 smoke compartments in Main Campus and 3 of 16 smoke compartments in West Campus.
The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Findings include:

While inspecting hazardous areas on June 4, 2014 and June 5, 2014 , the maintenance person and surveyor found the ceiling in the Electrical Room on the 1st Floor near Cardiovascular Services in Main Campus were incapable of resisting smoke due to numerous openings and penetrations. It was also observed that Prep/ Hold Room 12 had wheelchairs stored in the room and the door of Prep/ Hold Room 12 did not have a self closing device.

These deficient practices have the potential of affecting 1 of 26 smoke compartments in Main Campus and 1 of 16 smoke compartments in West Campus.
The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and all states letter
Ref: S&C -07-05. This condition had the potential to affect the entire Main Campus facility.

Findings include:

While inspecting the exit access on June 4, 2014 and June 5, 2014 , the maintenance person and surveyor found required exits from the North Stairwell in the Main Campus for the 1st, 2nd, 3rd, and 4th Floors to be inaccessible and not leading to the public way. It was also observed the exit near Room 7 in the Heart Hospital in the Main Campus was not leading to the public way.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observations, the facility failed to provide a complete manual fire alarm system as directed by NFPA 101 Section 9.6, NFPA 72 Section 4-4.4.2.2.

Findings include:

On June 4, 2014 and June 5, 2014, the maintenance supervisor and surveyor observed the following areas did not have fire alarm signaling device:

1. 2 East Medical Surgical Center on 2nd Floor was missing emergency horn strobes. (Main Campus)

2. The compartment between Specialty Hospital and Sleep Center on 3rd Floor was missing emergency horn strobes. (West Campus)

3. The compartment between Jenkins Clinic and Geriatric Unit on 2nd Floor was missing emergency horn strobes. (West Campus)

4. The Elevator Shaft #1 on the 4th Floor was missing a smoke detector. (West Campus)

5. The Nursing Station in the GI Lab on the 1st Floor was missing a smoke detector. (West Campus)

These deficient practices have the potential of affecting 1 of 26 smoke compartments in Main Campus and 4 of 16 smoke compartments in West Campus.
The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. This condition affected 100% of the residents and staff as all smoke compartments were affected. NFPA 72 Section 1-5.6

Findings include:

On June 4, 2014 and June 5, 2014, the maintenance supervisor and surveyor observed that all emergency strobes lights need to be synchronized in all the smoke compartments of the Main Campus Facility.

This condition had the potential to affect the entire Main Campus facility.
The maintenance supervisor and the administrator were notified during an exit conference.