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Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that corridor head room met the requiremnts of the Life Safety Code.
This could place all Patients and staff residents at risk in the event of fire or other emergency.
The findings include:
During a tour of the facility with Staff on 05/13/2019 between 06:30 am and 01:00 pm observation revealed that there was a monitor mounted on the wall in the corridor on 6th floor that extended more than 6 inches into the corridor.
These findings were confirmed by Staff at the time of discovery.
Reference:
2012 NFPA 101 Chapter 19 Section 19.2.1 and Section 7.1.5.1

Based on observation and staff interviews it was determined the facility failed to ensure that there were no dead end corridors that exceed 30 feet.
This could place 18 persons at risk in the event of fire or other emergency.
The findings include:
During a tour of the facility with Staff on 05/13/2019 between 06:30 am and 01:00 pm observation revealed that the corridor for the family sleeping area exceeds 30 feet with only one exit provided.
These findings were confirmed by Staff M at the time of discovery.
Reference:
2012 Ed. NFPA 101 Chapter 19 Section 19.2.5.2

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that exit signage clearly identified the exit on the 3rd floor.
This could place all patients and staff at risk in the event of fire or othe emergency.
The findings include:
During a tour of the facility with Staff M on 05/13/2019 between 06:30 am and 01:00 pm observation revealed that the exit at staff lounge on the 3rd floor AFLAC Cancer Unit is not obvoius and needs a directional arrow to indicate the exit door.
These findings were confirmed by Staff at the time of discovery.
Reference:
2012 Ed. NFPA 101 Chapter 19 Section 19.2.10.1

Based on observation and staff interviews it was determined the facility failed to ensure that vertical openings for cable runs were sealed properly.
This could place all patients and staff at risk in the event of a fire.
The findings include:
During a tour of the facility with Staff on 05/13/2019 between 06:30 am and 01:00 pm observation revealed that cable penatrations in the Data Closet near the elevators had holes around the cables where the Fire Stopping material is not installed properly. This condition is present on the 5th, 4th, 3rd, and 2nd floor in this location.
These findings were confirmed by Staff at the time of discovery.
Reference:
2012 Ed. 2012 NFPA 101 Chapter 19 Section 19.1.1, Chapter 8 Section 8.5.6

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that smoke detectors are installed properly at smoke doors provided with hold open devices.
This could place all patients and staff at risk in the event of a smoke or fire event.
The findings include:
During a tour of the facility with Staff on 05/13/2019 between 06:30 am and 01:00 pm observation revealed that the in the west section of tower 2 smoke detectors were not provided within 5 feet on both sides of smoke doors provided with hold open devices.
These findings were confirmed by Staff M at the time of discovery.
Reference:
2012 NFPA 101 Chapter 19 section 19.2.2.2.2; Chapter 7 section 7.2.1.8.2

2010 NFPA 72 Chapter 17 section 17.7.5.6

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure the sprinkler instalation met the requirements of NFPA 13.
This could place all patients and staff at risk in the event of a fire.
The findings include:
During a tour of the facility with Staff on 05/13/2019 between 06:30 am and 01:00 pm observation revealed that there was no sprinkler protection under the "cloud" features that are over 4 feet wide.
Reference:
2012 NFPA 101 Chapter 19 section 19.4.2.1; Chapter 9 section 9.7.1.1. (1) ; 2010 NFPA 13 Chapter 8 section 8.5.5.3.1
During a tour of the facility with Staff on 05/13/2019 between 06:30 am and 01:00 pm observation revealed that the escutchieon plate was missing at Room 185 Soiled utility room .
Reference:

2012 NFPA 101, Chapter 19, Sections 19.1.6.1, 19.3.5.1, 19.3.5.3, 19.3.5.4, Chapter 9, Sections, 9.7.5, 9.7.6, 9.7.1.1 and 2011 NFPA 25. Chapter 5, Sections; 5.2.1.1.2 & 5.2.1.1.4, (explanation in Annex E, E.1, Table E.1), and 2010 NFPA 13, Chapter 6, Section 6.2.7


These findings were confirmed by Staff at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to
This could place all patients and staff at risk in the event of a fire or smoke event.
The findings include:
During a review of the facility records with Staff on
05/10/2019 between 10:00 am and 01:00 pm records review and staff interview revealed that no documentation of a functional test of the smoke removal system installed in the Atrium.
These findings were confirmed by Staff at the time of discovery.
Reference:
2012 Ed. Chapter 19 Section 19.7.7