Smoke Compartment Size Exceeds NFPA 101 Standards
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to comply with the NFPA 101 requirements for smoke compartments on the 1st floor, as observed during a survey conducted on April 22, 2023. The smoke compartment exceeded the maximum allowable size of 22,500 square feet, which is a violation of the standards set for smoke barriers in buildings with a patient bed capacity of 30 or more. This deficiency was confirmed during an exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025.
Plan Of Correction
The facility will request the Division of Safety to conduct an FSES Survey.