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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 doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.

Observation determined the door to the Southwest Mechanical Room on the Nursing Facility Floor did not have self-closing hardware.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk of death or injury due to fire.

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

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 west exterior exit discharge traversed the lawn to get to a public way.

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

The deficiency affected one (1) of three (3) paths of egress from the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1, 9.6.1.4, NFPA 72 7-3.2

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

1) Review of fire alarm system test records indicated the annual test of the fire alarm system was not performed as required. The most current fire alarm system annual test was conducted on 01/11/2016 and the previous test was conducted on 12/08/2014, exceeding the required annual testing requirement.

2) Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The most current fire alarm system batteries load voltage test was conducted on 01/11/2016 and the previous test was conducted on 05/29/2015, exceeding the required semiannual testing requirement.

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 one (1) fire alarm system. The fire alarm system serves the entire 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 doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.

Observation determined the door to the Southwest Mechanical Room on the Nursing Facility Floor did not have self-closing hardware.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk of death or injury due to fire.

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

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 west exterior exit discharge traversed the lawn to get to a public way.

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

The deficiency affected one (1) of three (3) paths of egress from the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1, 9.6.1.4, NFPA 72 7-3.2

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

1) Review of fire alarm system test records indicated the annual test of the fire alarm system was not performed as required. The most current fire alarm system annual test was conducted on 01/11/2016 and the previous test was conducted on 12/08/2014, exceeding the required annual testing requirement.

2) Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The most current fire alarm system batteries load voltage test was conducted on 01/11/2016 and the previous test was conducted on 05/29/2015, exceeding the required semiannual testing requirement.

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 one (1) fire alarm system. The fire alarm system serves the entire facility.