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The facility failed to maintain the means of egress in accordance with Chapter 7.

1) 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

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

a) The corridor door to the Linen Closet by Room 173.
b) The corridor door to the Nourishment Center by Room 167.
c) The corridor door to the Coat Closet by Room 167.
d) The corridor door to the Housekeeping Closet by the Waiting Room.
e) The corridor door to the South Stairway on the Main Level.

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 five (5) of numerous corridor doors in the means of egress throughout the facility.

2) Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 4 1/2 in. (114 mm) on each side shall be permitted at 38 in. (965 mm) and below. 7.1.10.1, 7.3.2.2

Observation determined a water fountain located in the corridor by the Central Service Room in the Basement extended approximately eight (8) inches from the corridor wall and protruded into the exit corridor.

Failure to ensure exit access is readily available at all times increases the risk of death or injury due to fire.

This deficiency affected egress from one (1) of four (4) smoke compartments in the facility.

3) Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this code. 8.3.3.1.

Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2

Review of documentation and interview with staff determined fire rated door assemblies had not been inspected in the past year.

Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire.

This deficiency affected all fire rated door assemblies throughout the facility.

Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. Changes in elevation exceeding 1/4 in., but not exceeding 1/2 in., shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in. shall be considered a change in level and shall be subject to the requirements of 7.1.7.
Changes in level in means of egress not in excess of 21 in. shall be achieved either by a ramp or by a stair. Where a ramp is used, the presence and location of ramped portions of walkways shall be readily apparent.
Where a stair is used, the tread depth of such stair shall be not less than 13 in. The presence and location of each step shall be readily apparent. NFPA 19.2.1, 7.1.6.2, 7.1.7, 7.1.7.2

The facility failed to maintain the means of egress as required.

Observation determined the concrete sidewalk near Exit Door 3 had a break with a three (3) in. abrupt change in elevation. Abrupt changes in elevation exceeding 1/2 in. are subject to the requirements of ramps or stairs.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one location in numerous paths of egress from the facility.

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 in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and latching doors.

Observation determined:

1) The corridor door to the Dirty Utility Room by Room 167 failed to self-close and latch.

2) The corridor door to the Lab was not equipped with a self-closing device.

3) The east corridor door to the Laundry failed to self-close and latch.

Failure to ensure hazardous areas were separated from other spaces by smoke-resisting partitions increases the risk of death or injury due to fire.

The deficiency affected three (3) of numerous hazardous areas in the facility.

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. 19.3.2.5.1, 9.2.3, NFPA 96 11.2.1.

The facility failed to test and service the fire-extinguishing system serving the Kitchen exhaust hood in accordance with NFPA 96.

Record review determined the fire-extinguishing system serving the Kitchen exhaust hood was inspected and serviced on 05/18/2018 by an outside company. No other record was available in the past year.

Failure to inspect and service the fire-extinguishing system for the Kitchen exhaust hood at required intervals increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) required inspections of the Kitchen exhaust hood fire-extinguishing system in the past year.

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 03/27/2018. 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.

Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system. 19.3.5.1, 9.7.1.1(1), NFPA 13

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide adequate coverage for all portions of the building.

Observation determined there were numerous openings in the ceiling in an area under construction in the Boiler Room. The sprinklers in the area were at ceiling grid height and greater than 12 inches from the deck.

Failure to install and maintain the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected one (1) of numerous areas in the facility. The automatic sprinkler system serves the entire 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, 13.2.7.1, 13.3.2.1.1

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

Record review and interview with staff determined the control valves and the gauges of the automatic sprinkler system had not been inspected monthly.

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.

Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 19.3.6.3.5

The facility failed to ensure corridor doors latched into their frames and resisted the passage of smoke.

Observation determined the corridor door to the Linen Closet by Room 173 failed to latch into the frame.

Failure to ensure corridor doors latch properly increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor doors 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. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(A)(7)

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

Observation determined:

1) One (1) electrical receptacle in the Housekeeping Closet by the Waiting Room within 6 ft. of a floor sink was not ground-fault circuit-interrupter protected.

2) Two (2) electrical receptacles in the Emergency Room within 6 ft. of a sink were not ground-fault circuit-interrupter protected.

3) There were exposed electrical wires by the corridor door in the Center Stairway on the Main Level.

4) There were two (2) open electrical junction boxes in the Boiler Room.

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 electrical wiring and equipment in four (4) of numerous areas in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined:

1) Fire drills did not include the simulation of an emergency phone call to fire department.

2) No fire drills were conducted on the Day Shift during the fourth quarter of 2017 and the third quarter of 2018.

3) No fire drills were conducted on the Night Shift during the fourth quarter of 2017 and the first and second quarter of 2018.

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

The deficiency affected all fire drills.

A remote annunciator that is 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. The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
1) Individual visual signals shall indicate the following:
a) When the emergency or auxiliary power source is operating to supply power to load
b) When the battery charger is malfunctioning
2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
a) Low lubricating oil pressure
b) Low water temperature
c) Excessive water temperature
d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
e) Overcrank (failed to start)
f) Overspeed
NFPA 99 6.4.1.1.17

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 at a work site readily observable by personnel.

Failure to ensure the emergency generator was in compliance with NFPA 99 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.

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) The minimum exhaust temperature provided by the manufacturer was achieved or 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.

2) The weekly inspection of the emergency generator was not conducted for all months during the past year.

3) The monthly testing of the emergency generator was not conducted for all months during the past year.

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.