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The facility failed to ensure the means of egress was continuously maintained free of all obstructions to full use in case of emergency.

Observation determined:

1) There was a wooden shelf attached to the corridor wall that extended 10-inches into the corridor in the south, west, and north wings on the second floor. The shelves were approximately 44-inches above the floor.
2) The corridor door to the dietary dumb-waiter on the second floor opened outward into the exit corridor and did not open to within 7-inches of the corridor wall when fully opened. The door extended approximately 3-feet into the exit corridor.
3) There was a water fountain on the second floor in the south wing mounted to the corridor wall that extended 9-inches into the exit corridor.

Failure to ensure the means of egress is maintained free of obstructions increases the risk of injury or death due to fire.

This deficiency affected four (4) of four (4) exit corridors on the second floor.

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.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure hazardous areas were separated from other areas with self-closing doors.

Observation determined the corridor door to the Boiler Room failed to self-close and latch.

Failure to ensure hazardous areas were separated from other spaces by self-closing, latching doors increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous hazardous areas in the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3. 2010 NFPA 72, 14.1.1

The facility failed to test the fire alarm system as required.

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e)

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 08/02/2018. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to install, 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.

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 two (2) smoke detectors in the Main Lobby and one (1) smoke detector in the exit corridor on the first floor near the Kitchen were mounted on the ceiling within 3-feet of an air diffuser.

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

This deficiency affected three (3) of numerous smoke detectors in the 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 areas other than kitchens where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. NFPA 70, 210.8, 210.8(A)(7)

The facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code.

Observation determined an electrical receptacle in the Conference Room on the first floor was installed within 6 ft. of a sink and was 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 one (1) of numerous receptacles throughout the facility.