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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. These deficiencies affect 1 of 2 smoke compartments.¹

Findings include:

1. During an observation on 7/20/16 at 8:35 a.m., the North wing of patient rooms had an exit sign posted above the double doors to enter the corridor to access room 12. The exit sign directed entrance into the corridor outside room 12. The exit was before the doors leading into the corridor and did not have a chevron indicating the direction of the exit door. The corridor leading to room 12 did not have an exit sign showing the exit door out of the corridor.

2. During an observation on 7/20/16 at 8:30 a.m., the surgery department did not have exits signs leading to the path of egress from the surgery department.

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 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. These deficiencies affect 1 of 2 smoke compartments.¹

Findings include:

1. During and observation on 7/20/16 at 9:00 a.m., the laboratory department did not have exit signs leading to the path of egress.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 record review and interview, the facility failed to ensure emergency light 30 second monthly and 90-minute annual tests were conducted in accordance with NFPA 101, 2000 Edition, Section 7.9.3. This deficiency affects two fire/smoke compartments.

Findings include:

1. During review of facility records on 7/19/16, for testing emergency lighting, the facility was not able to provide documentation of 30 second monthly and 90 minute annual testing of the emergency lighting.¹

During an interview on 7/19/16 at 11:30 a.m., staff member A could not produce documentation that demonstrated where all emergency light fixtures were located, and whether they had been tested monthly and annually.

¹ NFPA 101, 2000 Edition, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment; A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and interview, the facility failed to perform fire drills every shift for every quarter in accordance with NFPA 101, 2000 Edition, Section 18.7.1.2. This deficiency affects two smoke compartments.

Findings include:

A review of facility records reflected a lack of fire drills for the 2nd shift of the first quarter of 2016 and both shifts for the 4th quarter of 2015.¹

During an interview on 7/20/16 at 7:45 a.m., staff member A stated the fire drills were not completed.

¹ NFPA 101, 2000 Edition, Section 18.7.1.2; 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 observation, the facility failed to ensure the integrity of the automatic sprinkler system was continuously maintained, inspected and tested periodically in accordance with NFPA 25, 1998 Edition. The deficiency affects 1 of 2 smoke compartments.

Findings include:

During an observation on 7/19/16 at 1:50 p.m., the clinic was observed. A ceiling tile was missing from an office on the northeast side of the clinic.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems,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.

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. These deficiencies affect 1 of 2 smoke compartments.¹

Findings include:

1. During an observation on 7/20/16 at 8:35 a.m., the North wing of patient rooms had an exit sign posted above the double doors to enter the corridor to access room 12. The exit sign directed entrance into the corridor outside room 12. The exit was before the doors leading into the corridor and did not have a chevron indicating the direction of the exit door. The corridor leading to room 12 did not have an exit sign showing the exit door out of the corridor.

2. During an observation on 7/20/16 at 8:30 a.m., the surgery department did not have exits signs leading to the path of egress from the surgery department.

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 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. These deficiencies affect 1 of 2 smoke compartments.¹

Findings include:

1. During and observation on 7/20/16 at 9:00 a.m., the laboratory department did not have exit signs leading to the path of egress.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 record review and interview, the facility failed to ensure emergency light 30 second monthly and 90-minute annual tests were conducted in accordance with NFPA 101, 2000 Edition, Section 7.9.3. This deficiency affects two fire/smoke compartments.

Findings include:

1. During review of facility records on 7/19/16, for testing emergency lighting, the facility was not able to provide documentation of 30 second monthly and 90 minute annual testing of the emergency lighting.¹

During an interview on 7/19/16 at 11:30 a.m., staff member A could not produce documentation that demonstrated where all emergency light fixtures were located, and whether they had been tested monthly and annually.

¹ NFPA 101, 2000 Edition, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment; A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and interview, the facility failed to perform fire drills every shift for every quarter in accordance with NFPA 101, 2000 Edition, Section 18.7.1.2. This deficiency affects two smoke compartments.

Findings include:

A review of facility records reflected a lack of fire drills for the 2nd shift of the first quarter of 2016 and both shifts for the 4th quarter of 2015.¹

During an interview on 7/20/16 at 7:45 a.m., staff member A stated the fire drills were not completed.

¹ NFPA 101, 2000 Edition, Section 18.7.1.2; 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 observation, the facility failed to ensure the integrity of the automatic sprinkler system was continuously maintained, inspected and tested periodically in accordance with NFPA 25, 1998 Edition. The deficiency affects 1 of 2 smoke compartments.

Findings include:

During an observation on 7/19/16 at 1:50 p.m., the clinic was observed. A ceiling tile was missing from an office on the northeast side of the clinic.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems,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.