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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 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/floor 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.

1) 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 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.

2) Doors are required to be arranged to be opened readily from the egress side. Locks, if provided, shall not require the use of special knowledge or effort for operation from the egress side. 7.2.1.5.1.

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

Observation determined the facility had not ensured that doors in the means of egress were not locked against egress when the building was occupied.

The east, west and south stairway doors from the second floor were found to be secured with a magnetic lock that required pushing a button to open the door. The doors were not equipped with a delayed egress feature.

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

The deficiency affected egress from three (3) of five (5) designated exits from the second floor in the facility.

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72 7-3.2

The facility failed to test the fire alarm system as required by NFPA 72, National Fire Alarm Code.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 09/23/2014. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.

1) All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110 3-5.5.6

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

Observation determined there was no remote stop switch for the generator located outside of the generator room.

2) Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days. NFPA 110 6-3.6

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

Record review determined the electrolyte levels of the emergency generator batteries were not checked at seven (7) day intervals as required.

3) A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. NFPA 99 3-4.1.1.15

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities.

Observation determined there was no remote annunciator located outside of the Generator Room at a work site readily observable by personnel.

Failure to inspect and maintain the 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.