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Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. The facility census was one.


1. Observation on 8/22/18, during the facility tour, showed the following;

-designated business southhall exit requires patients, staff and visitors to walk 50 feet to a hard surface. Fifty feet of path to hardpath consists of grass and would require patients, staff and visitors to travel down a steep hill.

Record review of the facility layout showed the exit discharge area designated for resident use.

During an interview on 8/22/18 at 11:35 A.M., the Director of Plant Operations confirmed the observation.


The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:
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7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4.

Based on staff interview and record review, facility staff failed to inspect and test one of two wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was one.

Record review on 8/22/18 did not show the 5 year internal pipe inspections & gauge replacements/calibrations for the one wet sprinkler systems. In addition, record review did not show quarterly tests on the wet sprinkler system

During an interview on 8/22/18 at 1:30 P.M., the Director of Plant Operations said he did not have documentation that the five year internal pipe inspection was conducted. In addition, the Director of Plant Operations said he did not have documentation of quarterly flow tests.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on observation, interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the fire egress doors. The facility census was one.

1. Review of the facility's inspection, testing and maintenance records for the 2017/18 year showed the records did not contain documentation of an annual inspection of the fire egress doors during the 12-month period.

During an interview on 8/22/18 at 1:42 P.M., the Director of Plant Operations said he/she did not know of the requirement to conduct annual inspections of the egress doors.


Review of NFPA 101, 2012 Edition showed the following:
-7.1.10.2.1 showed no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.
-19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
-7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7;
(2) Door assemblies in exit enclosures;
(3) Electrically controlled egress doors;
(4) Door assemblies with special locking arrangements subject to 7.2.1.6.
-7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
-7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
-7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction.

Based on interview and record review the facility failed to ensure fire drills were conducted quarterly. The facility census was one.

1. Review of the facility's fire drill records showed no documentation that a fire drill was conducted for the 7:00 A.M., to 7:00 P.M., shift for the third quarter of 2017. Additional review showed no documentation that a fire drill was conducted for the 7:00 P.M., to 7:00 A.M., shift for the fourth quarter of 2017.

During an interview on 8/22/18 at 12:00 P.M., the Director of Plant Operations said that he did not have documentation that the drills were conducted.