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Based on observation and interview, the facility did not provide enclosures around exit stairs by not having openings to unoccupied rooms. This deficiency occurred in 2 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On September 1, 2015, observation revealed on the 1st floor in the boiler room that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

2. On September 1, 2015, observation revealed on the 3rd floor in the penthouse that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

A waiver has been requested.

Based on observation and interview, the facility did not maintain a written evacuation plan that included staff being trained on life safety procedures. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On September 1, 2015 at 2:20 PM observation and interview revealed on the lower level floor in the kitchen, that the staff were not familiar with their responsibilities in the event of a fire. Staff M was asked what she would doif there was a fire on the grill. She was unfamiliar with the grease hood extinguishment system and did not know there was a manual pull to activate the kitchen hood system. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities) and staff C (cook) and staff M, (night cook).