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Based on observations, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. This deficiency affects 1 of 2 smoke compartments.

Findings include:

During an observation on 10/20/16 at 7:35 a.m., the corridor that ran perpendicular to the second floor corridor that ran east and west contained a physical therapy suite and a shipping and receiving suite next to each other. Stepping out of these suites looking to the left the sign on the corridor door read "not an exit" there was not a visible exit sign. The sign in the second floor corridor that ran east and west had a sign that was turned such that it could not be read from the door way of the physical therapy suite.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4; Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observation, the facility failed to provide for separation of the exit stairway from other parts of the building in accordance with NFPA 101, 2000 Edition, Section 7.1.3.2.1. This deficiency affects 2 of 2 smoke compartments.

Findings include:

During an observation on 10/20/16 at 9:27 a.m., the stairway adjacent to the laboratory at the second floor level was open to the corridor.¹ Required means of egress, including stairways, should be separated from other parts of the building with at least 1 hour construction.

¹ NFPA 101, Life Safety Code, 2000 Edition, Section 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 3: One-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.

Based on observation and interviews, the facility failed to have all egress exits arranged so that exits were readily accessible at all times in accordance with NFPA 101, 2000 Edition, Sections 19.2.2.2.4 and 7.2.1.6.2. The deficiency affects 4 of 4 smoke compartments for both buildings.

Findings include:

1. In an interview on 10/20/16 at 7:15 a.m., staff member A said that the exit out of the main entrance from the lobby is locked between 5:00 p.m. to 7:00 a.m. and that with the wander guard system the doors lock anytime a resident with a wander guard approaches this exit. It then requires the use of a keypad to unlock the doors. With a mixture of clinical (Alzheimer's or dementia) and non-clinical need residents/patients, the means of egress requirements for the non-clinical need residents overrides the needs of the clinical need.¹ ²

During an observation on 10/20/16 at 8:20 a.m., staff member A used a wander guard device to show how the second door locked when approached with wander guard.

2. During an observation on 10/20/16 at 10:02 a.m., the east side exit led to a fenced in courtyard with two gates. Both gates were pad locked.¹ ²

In an interview on 10/20/16 at 10:02 a.m., the door out of the east corridor locked at night with a mag lock that was triggered by the computer. The door also locked like the front entrance when someone with a wander guard approached.¹


¹ NFPA 101, Life Safety Code, 2000 Edition, Section 19.2.2.2.4, Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

² NFPA 101, 2000 Edition, Section 7.2.1.6.1 Delayed-Egress Locks; Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation, the double doors in the corridor separating the old nursing home and the hospital were not being maintained to prevent the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 19.2.2.5 and failed to latch per NFPA 80, 1999 Edition, Section 2-1.2. This deficiency affect 3 of 4 smoke compartments in Buildings 01 and 02.

Findings include:

1. During the observation on 10/20/16 at 8:40 a.m., the corridor double doors separating Building 01 from 02 were exercised and observed. The following deficiencies were identified:
a.) one of the two doors had a notch cut out on one of the doors that was measured as more than a quarter inch opening ¹, and
b.) these doors should have latching hardware as they serve as a horizontal exit. No latching hardware was present.²

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

² NFPA 80 Standard for Fire Doors and Fire Windows,1999 Edition, Section 2-1.2 Components; A fire door assembly shall consist of components that are separate products incorporated into the assembly and allowed to have their own subcomponents. The normal components of a fire door assembly include a door, a door frame, hinges, a lock or latch, and a closing device. They also include, but are not limited to, an astragal, an automatic louver, a coordinator, flush or surface bolts, gasketing, a holder/release device, protection plates, and glazing materials.

Based on record review and interview, the facility failed to perform fire drills quarterly on each shift in accordance with NFPA 101, 2000 Edition, Section 19.7.1.2. This deficiency affects both buildings smoke compartments.

Findings include:

In an interview on 10/19/16 at 11:30 a.m., staff member B said the facility operated two 12 hour shifts.

During review of the fire drills documented for the period January 2016 to October 2016 and November 2015 to December 2015, there was no evidence of drills being conducted for the day shift (6 a.m. to 6 p.m.) for the 2016 quarters of January to March, April to June, and July to September. Review of the drills showed that there was no evening quarter drill run for the quarter of July to September.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 19.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on record review, the facility failed to have evidence of smoke detector sensitivity testing in accordance with NFPA 72, 1999 Edition, Section 7-3.2.1. The deficiency effects all 4 smoke compartments in both buildings.

Findings include:

Review of facility fire inspection records did not include evidence of smoke detector sensitivity testing.

At the time of the exit on 10/20/16 at 3:30 p.m., the facility was reminded of not having the sensitivity reports.¹

¹ NFPA 72, National Fire Alarm Code® 1999 Edition, Section 7-3.2.1*; Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

Based on record review and observation, the facility failed to ensure components of the sprinkler system were inspected and tested in accordance with NFPA 25, 1998 Edition, Sections 2-2.6, 2-3.3, 9-2.6 and 9-7.1, that sprinklers were positioned so as not to affect activation time in accordance with Section 5-5.1, sprinklers were free from foreign materials per Section 2-2.1.1, and that sprinkler protection was extended under duct work that was over four feet wide in accordance NFPA 13, 1999 Edition, Section 5-5.5.3.1 & sprinkler clearance to storage was not less than 18 inches per Section 5-6.6. These deficiencies affect the two floors of the building.

Findings include:

1. Review of the facility's sprinkler inspection showed they had been conducted on the following dates: 9/6/16, 5/31/16, 3/18/16, 10/29/15, 9/8/15, and 2/24/15. Therefore, it could not be assured that alarm devices and the fire department connection were being inspected and tested on a quarterly basis and the main drain test was conducted annually.¹

2. During an observation on 10/19/16 at 2:45 p.m., in the heating, ventilation, and air conditioning (HVAC) room adjacent to the maintenance area there were two sections of duct work over 4 feet wide with no sprinkler protection underneath.²

3. During an observation on 10/19/16 at 3:30 p.m., an annular opening existed around the sprinkler in the emergency room.³

4. During an observation on 10/19/16 at 3:30 p.m., in the dining room across from the emergency room a sprinkler was covered with lint.(4)

5. During an observation on 10/19/16 at 3:33 p.m., in an alcove off the dining room there was 12 inches between the top shelf storage and the sprinkler in the ceiling.(5)

6. During an observation on 10/19/16 at 4:08 p.m., in the waiting room on second floor east, the escutcheon ring of the sprinkler head did not fit flush with the ceiling.³

7. During an observation on 10/20/16 at 8:20 a.m., a section of lay-in ceiling tile was out of place next to a sprinkler.³

8. During an observation on 10/20/16 at 9:40 a.m., an escutcheon ring was out of place in the ceiling of the east side utility room.³

9. During an observation on 10/20/16 at 9:43 a.m., an escutcheon ring in the tub room ceiling had an opening around it.³

¹ NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, 1998 Edition, Section 2-2.6 Alarm Devices; Alarm devices shall be inspected quarterly to verify that they are free of physical damage. Section 2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. 9-2.6* Main Drain Test. A main drain test shall be conducted quarterly at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves. Section 9-7 Fire Department Connections. 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-5.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place such as conference tables.

³ NFPA 13, 1999 Edition, Section 5-1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

(4) NFPA 25, 1998 Edition, Section 2-2.1.1; Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

(5) NFPA 13, 1999 Edition, Section 5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers); The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception: Where other standards specify greater minimums, they shall be followed.

Based on record review, the facility failed to document the weekly visual checks for the past year and the 30 minute monthly load tests on the generator for the month of June 2016 in accordance with NFPA 110, 1999 Edition, Section 6-3.4 and 6-4.1. This deficiency affects 4 of 4 smoke compartments for both buildings.

Findings include:

Review of the the facility's documentation for the generator showed monthly load test except for 6/2016. There was no evidence of weekly test.¹ ²

Staff member A was reminded of the need to see the documentation of the weekly test at the survey exit.

¹ NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-3.4; A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

² NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-4.1*; Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. These deficiencies affect 1 of 2 smoke compartments.

Findings include:

1. During an observation of the second floor nurses station on 10/19/16 at 3:40 p.m., a power strip under the desk was suspended by its power cord.¹

2. During an observation on 10/19/16 at 3:45 p.m., resident/patient room 220 was reviewed. The following deficiencies were noted:
a.) a power strip was not verifiable as a UL1363, and
b.) a refrigerator was plugged into the power strip.¹

3. During an observation on 10/19/16 at 4:00 p.m., in resident room 224 a power strip that was not verifiable as UL1363 was in use.¹

4. During an observation on 10/20/16 between 9:43 a.m. to 10:02 a.m., power strips that were not verifiable as UL1363 were found in rooms:
a.) 104,
b.) 106, and
c.) 108.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.