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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) Obstruction on corridor wall exceeds six inches into the means of egress from patient sleeping rooms. Location: Comments box next to elevators.

Life Safety Code section 19.2.3.4(2) requires, in part, where corridor width is at least six feet, noncontinuous projections not more than six inches from the corridor wall, above handrail height, shall be permitted.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 of 3 smoke compartments. Deficient items were discussed with the Facility Manager and Facility Operations Manager 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 and NFPA 25. This was evidenced by:

1) Sprinkler head showing signs of corrosion in the shower room.

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 section 5.2.1.1.1; sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 of 3 smoke compartments. Deficient items were discussed with the Facility Manager and Facility Operations Manager 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 and NFPA 10. This was evidenced by:

1) Top of portable fire extinguisher installed more than 5 feet above the floor in the Rehabilitation Room.

Life Safety Code section 19.3.5.12 to comply with section 9.7.4.1. Section 9.7.4.1 to comply with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 section 6.1.3.8.1, "Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 of 3 smoke compartments. Deficient items were discussed with the Facility Manager and Facility Operations Manager 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) Blow-out patches used on one hour rated smoke barrier. Drywall patches must be an approved UL listed assembly and flush with the smoke/fire barrier wall. Location: Above smoke barrier doors next to the biohazard room.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 2 of 3 smoke compartments. Deficient items were discussed with the Facility Manager and Facility Operations Manager 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) Fire safety plan does not contain all required elements. The plan is missing the emergency phone call to the fire department.

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 Facility Manager and Facility Operations Manager during the exit conference.