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Based on observation the facility needs to provide second means of egress signage at 1st floor corridor.

Based on observation the facility failed to provide adequate support for low voltage wires above ceiling throughout facility. Verify all low voltage wires are properly secure.

Bundle, secure, and support all low-voltage and signal wiring, cable, pneumatic tubing, fiber optics, etc. above the ceiling.
NFPA 70,: 300-11(a)


Based on observation the facility failed to provide adequate protection at rated walls. Verify all rated walls meets requirement.

"Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device." - NFPA 101, 2003, 8.3.5.1.


Based on observation the facility failed to provide adequate door latching functions at various locations. Verify all doors with closer latch properly.

All doors that are required to have closers except for cross corridor doors must latch on their own after closing. "Fire doors shall be self-closing or automatic-closing." - NFPA 101, 2003: 8.3.3.3 & 7.2.1.8.


Based on observation the facility failed to provide adequate smoke mitigation bewtween smoke compartments. Verify all doors at smoke barries meet requirement.

Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullion shall be prohibited - NFPA 101, 2003: 18.3.7.10



Based on observation the facility failed to provide adequate tamper proof fixtures and hardware. Verify all requirements are met.

Special fixtures, hardware, and tamper-proof screws. Special fixtures, hardware, and tamper-proof screws shall be used throughout the patient nursing suites.

(I) All exposed and accessible fasteners shall be tamper-resistant.

(II) Suitable hardware shall be provided on doors to toilet rooms so that access to these rooms can be controlled by staff. Hardware shall be utilized which is appropriate to prevent patient injury.

(III) Only break-away or collapsible clothes bars in wardrobes, lockers, towel bars, and closets and shower curtain rods shall be permitted. Wire coat hangers shall not be permitted in nursing suites.

(IV) When grab bars are provided, the space between the grab bar and the wall should be filled to prevent a cord being tied around it for hanging. Bars, including those which are part of such fixtures as soap dishes, shall be sufficiently anchored to sustain a concentrated load of 250 pounds. 2004, §134.123(n)(vii)(I)(II)(III)(IV).



Based on observation the facility failed to provide adequate tamper proof fixtures and hardware. Verify all requirements are met.

Detention screens.

(I) When operable windows are provided in patient sleeping rooms, it may be necessary to provide detention screens on windows or limit the amount of window operation in order to inhibit possible tendency for suicide or elopement. The type and the degree of security required shall be determined by the facility administration.

(II) When detention screens are provided, windows shall be capable of opening with the screens in place. Where glass fragments may create a hazard, safety glazing or other appropriate security features shall be incorporated.

(III) In building housing for certain types of patients, detention rooms, or a security section, the facility shall provide detention screens to confine or protect building inhabitants, when necessary.2004, §134.123(n)(viii)(I)(II)(III).