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Based on observation and interview, it was revealed the facility construction type does not meet, evidenced as follows;

Findings include:

On 12/20/16 at approximately 11:42 A.M., it was observed during review of documentation that the Fire Safety Equivalency Survey provided for the facility to meet the height and area requirements has not been updated to meet the 2012 Life Safety Code.

The Director of Facilities witnessed this evidence by observation and interview.

Fire Safety Equivalency Surveys are used for the building to comply with the Life Safety Code exit discharge requirements.

Based on observation and interview, it was revealed the facility failed to maintain proper exit discharge, evidenced as follows;

Findings include:

1. On 12/20/16, at various times it was observed during inspection that the Mundy building North East emergency egress stairwell discharges into a corridor on the 2nd floor before exiting to the outside. The existing FSES has not been updated to show compliance with the 2012 Life Safety Code for exit discharge.

2. On 12/20/16, at various times it was observed during inspection that the Krise building South West emergency egress stairwell discharges into an elevator lobby on the 2nd floor before exiting to the outside. The existing FSES has not been updated to show compliance with the 2012 Life Safety Code for exit discharge.

Reference Code NFPA 101, 2012 - Section 7.2.3.5

The Director of Facilities witnessed this evidence by observation and interview.

Based on observation and interview, it was revealed the facility failed to maintain rated doors, evidenced as follows;
Findings include;

On 12/20/16 at approximately 2:21 P.M., it was observed during inspection that one leaf of the cross corridor double doors at room 11 has a missing a door edge plate at the latch, leaving a breach in the surface of the door.

The Director of Facilities witnessed this evidence by observation and interview.

Based on observation and interview, it was revealed the facility failed to maintain the fire alarm system, evidenced as follows;

Findings include:

On 12/20/16 at approximately 2:21 P.M., it was observed during the survey and upon review of documentation that the fire alarm system is in the process of being upgraded, is incomplete at this time, and no final acceptance testing has been conducted..

The Director of Facilities witnessed this evidence by observation and interview.

Based on observation and interview, it was revealed the facility failed to provide complete sprinkler protection, evidenced as follows;

Findings include:

On 12/20/16, it was observed during inspection the North East 2nd floor exit access corridor from the 5th floor Critical Care area stairwell is not protected by sprinklers.

The Director of Facilities witnessed this evidence by observation and interview.

Based on observation and interview, it was revealed the facility failed to maintain the sprinkler system, evidenced as follows;

Findings include:

1. On 12/20/16 at approximately 2:29 P.M., it was observed during inspection there is a corroded sprinkler in shower room 5054.

2. On 12/20/16 at approximately 2:49 P.M., it was observed during inspection a sprinkler cover plate in Activity room 5142 appears to be adhered to the ceiling with caulk.

3. On 12/20/16 at approximately 3:52 P.M., it was observed during inspection a sprinkler cover plate in the corridor at the Physical Therapy Gym appears to be adhered to the ceiling with caulk.

4. On 12/20/16 at approximately 2:55 P.M., it was observed during inspection there is a corroded sprinkler in the mechanical room near the Rivermont Nurses' Station.

The Director of Facilities witnessed this evidence by observation and interview.

Based on observation and interview, it was revealed the facility failed to properly use electrical equipment, evidenced as follows;

Findings include:

1. On 12/20/16 at approximately 1:30 P.M., it was observed during the survey there are extension cords used to power decorations within patient care areas of rooms 1 & 2.

2. On 12/20/16 at approximately 3:13 P.M., it was observed during the survey there is a portable power tap device powered by another portable power tap device instead of powered directly by an electrical wall outlet.

The Director of Facilities witnessed this evidence by observation and interview.