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Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:

1) Door knob that serves an occupant load of 3 or more does not open in one releasing operation from the egress side of the door in the following locations:
a) Central Service room
b) Dirty Linen room

2) Closet in room 19 was secured with a hook and eye lock that cannot be opened from the inside.

Life Safety Code section 19.2.1 to comply with section 7.2.1. Section 7.2.1.5.10.2, in part, releasing mechanisms shall open the door with not more than one releasing operation. Furthermore, section 7.2.1.5.3 requires, "Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 2 of 4 smoke compartments. Deficient items were discussed with the Maintenance Director and Assistant Maintenance Director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:

1) Exit door outside of room 19 is blocked by a gate secured with a dead-bolt lock. The lock does not release upon loss of power nor does it release upon activation of either smoke detection or water flow activation.

Life Safety Code section 19.2.2.2.5.2 requires, "Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:
(1) Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
(2) A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
(3) *The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.1.
(4) The locks are electrical locks that fail safely so as to release upon loss of power to the device.
(5) The locks release by independent activation of each of the following: (a) Activation of the smoke detection system required by 19.2.2.2.5.2(2) (b) Water flow in the automatic sprinkler system required by 19.2.2.2.5.2(3)

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 of 4 smoke compartments. Deficient items were discussed with the Maintenance Director and Assistant Maintenance Director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:

1) Foldable chairs and table stored in the corridor of the hospital wing impedes clear width requirement.

Life Safety Code section 19.2.3.4 requires, in part, any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 of 4 smoke compartments. Deficient items were discussed with the Maintenance Director and Assistant Maintenance Director during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 96. This was evidenced by:

1) Service receipts were provided for the maintenance of the fire-extinguishing system to the facilities listed kitchen exhaust hood. There was no supporting documentation of the work completed during the time of inspection.

Life Safety Code section 19.3.2.5.1 to comply with section 9.2.3. Section 9.2.3, commercial cooking equipment to comply with NFPA 96. NFPA 96, section 11.2.8 requires, in part, certificates of inspection and maintenance shall be forwarded to the authority having jurisdiction.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 of 4 smoke compartments. Deficient items were discussed with the Maintenance Director and Assistant Maintenance Director during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25. This was evidenced by:

1) Service receipts were provided for both annual(12/27/18) and semi-annual(6/1/18) sprinkler system services. There was no supporting documentation of sprinkler system inspection, testing, and maintenance reports provided during the time of inspection.

2) Sprinkler pipe hanger was detached from the ceiling outside of room 19.

Life Safety Code section 19.3.5.1 to comply with section 9.7. Section 9.7.5 maintenance and testing to comply with NFPA 25. NFPA 25 identifies sprinkler system requirements per Table 5.1.1.2 "Summary of Sprinkler System Inspection, Testing, and Maintenance." Furthermore, NFPA 25 section 5.2.3.1 requires, "Hangers and seismic braces shall not be damaged or loose."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the Maintenance Director and Assistant Maintenance Director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

1) The following spaces were open to the corridor and not equipped with electrically supervised smoked detection:
a) Physical therapy area in the basement.
b) Alcove area adjacent to room 15.

Life Safety Code section 19.3.6.1(7) requires, "Spaces, other than patient sleeping rooms, treatment rooms, and hazardous areas, shall be permitted to be open to the corridor and unlimited in area, provided that all of the following criteria are met: (a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4. (b)*Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur. (c) The space does not obstruct access to required exits.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 2 of 4 smoke compartments. Deficient items were discussed with the Maintenance Director and Assistant Maintenance Director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

1) Double door that opens to the corridor is equipped with a flush bolt lock that was not latched into the door frame in the following locations:
a) Staff Dining room in the basement.
b) Kitchen in the basement.

Life Safety Code section 19.3.6.3.5 requires, "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 of 4 smoke compartments. Deficient items were discussed with the Maintenance Director and Assistant Maintenance Director during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the operating procedures requirements in accordance with NFPA 101. This was evidenced by:

1) The fire safety plan does not reflect evacuation of the smoke compartment and preparation of the building for evacuation.

Life Safety Code section 19.7.2.2 requires, "A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the Maintenance Director and Assistant Maintenance Director during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the Health Care Facilities Code requirements in accordance with NFPA 99 and NFPA 110. This was evidenced by:

1) No documentation of monthly testing/recording of electrolyte specific gravity or battery conductance test on generator lead-acid type batteries.

2) No remote manual stop provided for the emergency power supply.

3) Combustible storage not directly related to the generator located within the same room.

Health Care Facilities Code requires generator maintenance and testing to be in accordance with NFPA 110.
1) Section 8.3.7.1, maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.
2) Section 5.6.5.6 requires, "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building."
3) Section 7.11.1 requires, "The room in which the EPS equipment is located shall not be used for other purposes that are not directly related to the EPS. Parts, tools, and manuals for routine maintenance and repair shall be permitted to be stored in the EPS room."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the Maintenance Director and Assistant Maintenance Director during the exit conference.