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Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. The facility census was 312.


1. Observation on 11/27/18, during the facility tour, showed the following;

-designated surgical ICU exit requires patients, staff and visitors to walk 100 feet to a hard surface. Sixteen feet of path to hardpath consists of grass and a steep hill.

- designated east stair A exit requires patients, staff and visitors to walk into a courtyard where the hardpath is blocked by a gate. Observation showed patients, staff and visitors would have to manually lift up the gate to exit to the public way.

Record review of the facility layout showed the exit discharge areas designated for resident use.

During an interview on 11/27/18 at 1:20 P.M., the Division Director of Construction Management confirmed the observations.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:
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7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on observation and facility staff interview, the facility staff failed to provide and maintain one of one kitchen range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition requirements. The facility census was 312.

1. Observation on 11/27/18, during the facility tour, showed the range hood did not have a an enclosed metal container to collect grease from the drip tray.

During an interview on 11/27/18 at 1:30 A.M., The Division Director of Construction Management confirmed the observation.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 6.2.4.1 states: "Grease filters shall be equipped with a grease drip-tray beneath their lower edges.

Based on observation and interview the facility failed to install a sprinkler system in accordance with the National Fire Protection Association 13, Standards for the Installation of Sprinkler Systems in all areas of the facility. This deficient practice affects all patients in the facility. The facility census 312.



1. Observation on 11/27/18, during the facility tour, showed standard sprinkler heads mixed with quick response sprinkler heads in the operating room smoke compartment.

2. During an interview on 11/27/18 at 12:20 P.M., the Division Director of Construction Management confirmed the observation.

Section 8.3.3.2 of the National Fire Protection Association (NFPA 13) states: Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.