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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. CMS S&C-07-05

Observation determined the northeast exterior exit from St Andrews Health Center - CAH traversed the lawn to get to a public way.

Failure to ensure means of egress provide safe access to a public way increases the risk of death or injury due to fire.

This deficiency affected one (1) of nine (9) required exits from the building.

Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Automatic wet chemical fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and NFPA 17A, Standard for Wet Chemical Extinguishing Systems. 19.3.2.5.1, 9.2.3, NFPA 96 10.2.6(4).

1) The facility failed to install cooking equipment in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. 19.3.2.5.1, 9.2.3, NFPA 96 10.5.1.

Observation determined the manual actuation device for the fire-extinguishing system serving the Kitchen exhaust hood was mounted at a height of more than forty-eight (48) inches above the floor. The manual pull was 56 inches above the floor.

2) The facility failed to inspect, test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems and NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.

At a minimum, this quick check or inspection shall include verification of the following:

(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

If any deficiencies are found, appropriate corrective action shall be taken immediately.
Where the corrective action involves maintenance, it shall be conducted by a trained service technician.
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded.
The records shall be retained for the period between the semiannual maintenance inspections. NFPA 17A 7.2.1 through 7.2.6

Review of documentation and interview with staff determined the monthly inspections of the wet chemical extinguishing system in the Kitchen had not been completed during the past four months.

This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined one (1) smoke detector in the Emergency Room was installed within 36 in. of a return air opening.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than1/2-hour. 19.3.6.2.1

The facility failed to ensure corridors were separated from use areas by walls constructed with at least a 1/2-hour fire resistance rating.

Observation determined the fire rated corridor walls stopped at the ceiling and did not extend to the floor/ceiling or ceiling/roof assembly.

1) The plaster covering the clay tile corridor walls throughout the facility stopped at the suspended ceiling and was not applied to the clay tile block located in the interstitial space between the suspended ceilings and the floor/ceiling or the ceiling/roof decks. Without the plaster, the clay tile walls cannot attain a minimum 1/2-hour fire resistance rating.

2) A section of the second-floor dining room corridor wall was not constructed with gypsum board on the room side of the wall. The gypsum board on the dining room side of the wall stopped at the suspended ceiling and did not extend to the ceiling/roof assembly. Without gypsum board applied to both sides of the wall, this section of the corridor wall cannot attain a minimum 1/2-hour fire resistance rating.

Failure to separate corridors from other areas increases the risk of death or injury due to fire.

This deficiency affected all exit corridors in the facility.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens, rooftops, outdoors, indoor wet locations, locker rooms with associated showering facilities, garages and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(B)

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code.

Observation determined numerous electrical receptacles in the Kitchen were not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected numerous electrical receptacles in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined no fire drills were conducted on the PM Shift during the third quarter in the past year.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of twelve (12) drills in the past year.

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems.

Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Diesel-powered EPS installations that do not meet the requirements shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. NFPA 99 6.4.4.1.1.4, NFPA 110 8.4.2, 8.4.2.3

1) Review of generator test records and interview with staff did not indicate the minimum exhaust temperature provided by the manufacturer was achieved and that the monthly exercise of the 500 kW diesel generator loaded the generator to at least 30% (150 kW) of the nameplate rating. The facility did not perform annual supplemental load exercises as required when diesel generators are not loaded to 30% of nameplate rating or manufacturer's recommended temperature during the required monthly exercises.


2) Review of generator test records and interview with staff determined the emergency generator was not exercised under load for 4 continuous hours in the past 36 months.

Failure to inspect, test and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.