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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. 7.2.1.4.3.1

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

Observation determined the following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

1) The corridor door to the Housekeeping Room by the Main Nurses Station.
2) The corridor door to the Housekeeping Room by the Secondary Nurses Station.
3) The corridor door to the Linen Room in the south exit corridor.
4) The corridor door to the PT Storage Room in the south exit corridor.
5) The south corridor door to the Break Room.
6) The corridor door to the Ice Machine Room.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected six (6) of numerous corridor doors in the means of egress throughout the facility.

Testing of required emergency lighting systems shall be permitted to be conducted as follows:

1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered.
4) The emergency lighting equipment shall be fully operational for the duration of the tests.
5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.1

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Records review determined annual testing of the emergency battery-powered emergency lighting system was not documented.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. Grease filters that require a specific orientation to drain grease shall be clearly so designated, or the hood shall be constructed so that filters cannot be installed in the wrong orientation. 19.3.2.5.1, 9.2.3, NFPA 96 6.2.5.

The facility failed to properly install grease filters in the exhaust hood in the Main Kitchen in accordance with NFPA 96.

Observation determined two (2) of four (4) grease filters in the exhaust hood over the cooking equipment in the Main Kitchen were installed horizontally with the grease openings located at the sides of the filters instead of the vertical orientation to allow grease to drain.

Failure to properly install grease filters increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) commercial cooking exhaust hoods in the facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25

A main drain test shall be conducted annually 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. In systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis. NFPA 25, 13.2.5, 13.2.5.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review determined quarterly flow tests of the automatic sprinkler system were not completed as required. Records did not indicate flow tests were conducted during the first, second and third quarters of 2017.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 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 8.4.1, 8.4.2, 8.4.2.3

The facility failed to ensure the emergency generator was in compliance with NFPA 99 and NFPA 110.

Review of generator test records did not indicate:

1) That the generator was inspected during weeks 31, 33 and 52 of 2017.

2) That the generator was tested during the months of May and December of 2017.

3) That the minimum exhaust temperature provided by the manufacturer was achieved or that the monthly exercise of the diesel generator loaded the generator to at least 30% (30 kW) of the nameplate rating. The nameplate rating of the generator was 100 kW.

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 minimum exhaust gas temperatures were achieved during the required monthly exercises.

Failure to inspect and maintain emergency generators 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.