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The facility failed to ensure exit access was readily accessible at all times.

Observation determined:

1) Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall be permitted to discharge through areas on the level of exit discharge. 7.7.2

The facility failed to arrange at least 50 percent of exits to discharge directly to the exterior of the building.

The North, East, and Center stairways from the second floor discharged onto the first floor and did not exit directly to the outside.

This deficiency affected three (3) of four (4) designated exits from the second floor.

2) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.4.

The following corridor doors opened outward into the exit corridor and extended more than seven inches from the wall when fully opened:

1) The Trash Chute Room on the first floor.
2) The Medical Chute Room on the first floor.
3) The West Wing Storage Room on the second floor.
4) The East Wing Janitor Closet on the second floor.

This deficiency affected four (4) of numerous corridor doors in the means of egress throughout the facility.

3) Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

The facility failed to provide hard surfaces from all required exits to public ways.

Observation determined the exit from the West Wing traversed the lawn to get to a public way.

The deficiency affected one (1) of four (4) required exits from the building.

Failure to ensure exit access is readily available at all times increases the risk of death or injury due to fire.

The facility failed to install supervisory attachments on the automatic sprinkler system to monitor for integrity in accordance with NFPA 72, National Fire Alarm Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1.

Observation determined the sprinkler pipe valve between the antifreeze system and the wet pipe system in the Kitchen was not electronically monitored.

Failure to monitor sprinkler system control valves increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous control valves on the automatic sprinkler system. The automatic sprinkler system serves the entire building.