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2000 4.6.7 Modernization or Renovations. Any alteration or any installation of new equipment shall meet, as nearly as practicable, the requirements for new construction. Only altered, renovated, or modernized portions of an existing building, system, or individual component shall be required to meet the provisions of this Code that are applicable to new construction. If the alteration, renovation, or modernization adversely impacts required life safety features, additional upgrading shall be required. Existing life safety features that do not meet the requirements for new buildings, but that exceed the requirements for existing buildings, shall not be further diminished. In no case shall the resulting life safety features be less than those required for existing buildings.

19.2.3.3 Any required aisle, corridor, or ramp shall not be less than 4 ft in clear width where serving as means of egress from patient sleeping rooms. The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers.
Exception No. 1: Aisles, corridors, and ramps in adjunct areas not intended for housing, treatment, or use of inpatients shall be not less than 44 inches in clear and unobstructed width.
Exception No. 2: Exit access within a room or suite of rooms complying with the requirements of 19.2.5


Based on observation, the facility failed to maintain an exit access clear and unobstructed for 1 of 5 main exit corridors.

Findings include:

The main entrance/exit in front of the acute nurses station (heading east) was reduced from eight feet to six feet by a coffee table and some raffle prizes that the facility was promoting. The facility was designed and built with pre-existing eight foot corridors.

7.10.5.1 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

Based on observation, the facility failed to maintain 3 of 15 exit signs in the building.

Findings include:

The following exit signs were not illuminated at the time of the survey:
1) There were two exit signs in the kitchen heading out the rear exit that were not illuminated.
2) There was an exit sign located outside the CT (computerized tomography) scan room (leading north) that was not illuminated.

Based on observation, the facility failed to maintain 1 of 15 fire extinguishers in the facility.

Findings include:

There was a fire extinguisher in the treatment room north of the gym that had a tag dated 3/17/09 by Simplex Grinnell.

Based on observation, the facility failed to maintain 1 of 2 smoke/fire barriers in the facility to prevent the passage of smoke in the event of a fire or smoke emergency.

Findings include:

North of the acute nurses station, toward the physical therapy gym, there was a smoke/fire barrier. Above the drop in ceiling there were communications wires and a main sprinkler pipeline penetrating the barrier and the annular spaces for these penetrations were insufficiently fire caulked to limit the passage of smoke in an emergency.