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Any vertical opening shall be enclosed or protected in accordance with 8.2.5. 18.3.1.1

The facility failed to provide one-hour fire resistive construction for stairways.

Observation determined there was an unsealed sprinkler pipe penetration above the main floor north stairway door.

Failure to maintain vertical openings as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of four (4) stairways in the facility.

A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position. 18.3.1.2

The facility failed to provide self-closing stair enclosure doors.

Observation determined the basement northeast stairway door did not self-close and latch into the door frame.

Failure to maintain stair enclosure doors as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of eight (8) stairway doors in the facility.

Any hazardous area shall be protected in accordance with Section 8.4. 18.3.2.1

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

1) Observation determined the low-voltage wiring and electrical conduit penetrations through the hazardous area walls throughout the facility were not adequately sealed with fire rated material.

2) The door to the Power Room had an unsealed space around the door handle.

3) The south leaf of the double doors to the Maintenance Office did not have automatic latching hardware.

4) The door to the IT office / Storage Room failed to self-close and latch when tested.

5) The door to the Clean Utility Storage Room failed to self-close and latch when tested.

6) The door to the PT Storage Room did not have self-closing hardware.

7) The door to the Soiled Utility Room did not have self-closing hardware.

8) The door to the Kitchen Storage Room did not have self-closing hardware.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected numerous hazardous areas in the facility.

The facility failed to ensure exit access was readily accessible at all times.

1) Stairs shall be in accordance with 7.2.2.2.1

Observation determined two (2) of four (4) exit stairs had obstructions that reduced the clear width of the stairs to less than 44 inches.

a) A fixed heater was located in the southeast exit stair that reduced the width of the stairs to 40 inches.

b) A fixed heater was located in the east exit stair that reduced the width of the stairs to 36 inches.

2) 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.

Observation determined the north, northeast and east exterior exits transversed the lawn to get to a public way.

3) 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. 7.2.1.4.4.

Observation determined the door to Storage Room 116 opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

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

The deficiency affected access to the means of egress throughout the facility.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1½-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction. 7.9.3

Review of records indicated the facility failed to conduct annual 1½-hour tests on the emergency battery pack lights throughout the facility.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

Drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. 18.7.1.2

The facility failed to conduct fire drills as required.

Fire drill records review determined the facility failed to conduct fire drills during the third quarter in the past year.

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

The deficiency affected two (2) of eight (8) drills in the past year.

In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location. Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. NFPA 72 1-5.6

The facility failed to install the fire alarm system in accordance with NFPA 72, National Fire Alarm Code.

Observation determined the fire alarm panel located in the Power Room was not protected with an approved device.

Failure to install the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) fire alarm panel in the facility, which serves the entire building.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 18.3.4.1

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code.

1) System defects and malfunctions shall be corrected. NFPA 72 7-1.1.2

Observation determined the fire alarm panel was indicating a trouble condition for the lower heat detector in the Boiler Room that had failed and had not been repaired or replaced at the time of the survey.

2) System defects and malfunctions shall be corrected. NFPA 72 7-1.1.2

Record review indicated the fire alarm failed to transmit the alarm to emergency forces when tested in July 2015 and had not been repaired at the time of the survey.

3) 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 Code. 9.6.1.4

There was no record of the required fire alarm inspection and testing available.

Failure to maintain, inspect and test the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected numerous tests and components of the complete fire alarm system, which serves the entire facility.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years. NFPA 72 7-3.2.1

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72, National Fire Alarm Code.

There was no record of the required smoke detector sensitivity testing available.

Failure to maintain smoke detectors as required increases the risk of death or injury due to fire.

This deficiency affected the entire building.

Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 18.3.5.1

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:

1) The north Dietary Closet lacked sprinkler coverage.

2) There was no sprinkler coverage above the partial suspended ceilings in the Maintenance Office, Purchasing Office and Boiler Room.

3) The sprinklers in the Power Room, the Boiler Room and the Air Handler Room located south of the Laundry Room were not ordinary-temperature-rated, but were intermediate-temperature-rated. The sprinklers were green color coded which is an indication of an intermediate-temperature-rating. These sprinklers are to be used only when the maximum ceiling temperature exceeds 100°F but does not exceed 150°F.

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 six (6) of numerous areas in the facility.

Automatic sprinkler systems are continously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Record review and observation determined:

1) Automatic sprinkler system inspection and test records indicated the last inspection and test of the automatic sprinkler system was conducted on 08/15/2013, exceeding the required annual and quarterly inspection and testing requirements.

2) No record of the required annual back flow preventer test was available.

3) There were tiles missing from the suspended ceilings throughout the building that could delay the activation of the sprinkler system.

4) The shower curtain suspended from a ceiling mounted track obstructed coverage of the sprinkler in Patient Room 147.

5) The privacy curtains with no ½ inch mesh suspended from ceiling mounted tracks obstructed coverage of the sprinklers in Patient Rooms 163 and 165.

6) The privacy curtain with less than ½ inch mesh suspended from a ceiling mounted track obstructed coverage of the sprinkler in Patient Room 121.

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 numerous inspections, tests and components of the automatic sprinkler system, which serves the entire facility.

An inspection and servicing of the fire-extinguishing system and listed exhaust hoods shall be made at least every 6 months by properly trained and qualified persons. NFPA 96 11.2.1

The facility failed to inspect and service the fire-extinguishing system as required by NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

There was no record of the required inspection and servicing of the kitchen range hood fire-extinguishing system.

Failure to inspect and service the fire extinguishing system in accordance with NFPA 96 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire extinguishing system for commercial cooking operations in the building.

Portable space-heating devices shall be prohibited in all health care occupancies. Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C). 18.7.8

The facility failed to prevent the use of portable space heating devices in sleeping areas.

Observation determined an electric portable space heater was being used in the Doctor Sleeping Room.

Failure to prevent the use of portable space heating devices in sleeping areas increases the risk of death or injury due to fire.

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

1) All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110 3-5.5.6

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined there was no remote stop switch for the generator located outside of the generator enclosure.

2) The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. NFPA 110 5-3.1

Observation determined the emergency power transfer switches in the boiler room were not provided with battery powered emergency lighting as required.

Failure to provide emergency lighting at the emergency power transfer switches as required increases the risk of death or injury due to fire.

3) Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes. NFPA 110 6-4.1, 6-4.2

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Review of generator test records could not verify that weekly inspections and monthly 30-minute load tests were conducted in the past year.

Failure to inspect and maintain the emergency generator in accordance with 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.

Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. 18.5.1.1, 9.1.2

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined:

1) An extension cord and 3-way adapter were used in place of permanent wiring to provide power to a microwave and toaster in the Dining Room.

2) An extension cord was used in place of permanent wiring to provide power to a refrigerator in the Reporting Room.

3) There were numerous open electrical panels and junction boxes throughout the basement mechanical rooms.

Failure to comply with NFPA 70 increases the risk of death or injury due to fire.

This deficiency affected the entire building.

Any vertical opening shall be enclosed or protected in accordance with 8.2.5. 18.3.1.1

The facility failed to provide one-hour fire resistive construction for stairways.

Observation determined there was an unsealed sprinkler pipe penetration above the main floor north stairway door.

Failure to maintain vertical openings as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of four (4) stairways in the facility.

A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position. 18.3.1.2

The facility failed to provide self-closing stair enclosure doors.

Observation determined the basement northeast stairway door did not self-close and latch into the door frame.

Failure to maintain stair enclosure doors as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of eight (8) stairway doors in the facility.

Any hazardous area shall be protected in accordance with Section 8.4. 18.3.2.1

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

1) Observation determined the low-voltage wiring and electrical conduit penetrations through the hazardous area walls throughout the facility were not adequately sealed with fire rated material.

2) The door to the Power Room had an unsealed space around the door handle.

3) The south leaf of the double doors to the Maintenance Office did not have automatic latching hardware.

4) The door to the IT office / Storage Room failed to self-close and latch when tested.

5) The door to the Clean Utility Storage Room failed to self-close and latch when tested.

6) The door to the PT Storage Room did not have self-closing hardware.

7) The door to the Soiled Utility Room did not have self-closing hardware.

8) The door to the Kitchen Storage Room did not have self-closing hardware.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected numerous hazardous areas in the facility.

The facility failed to ensure exit access was readily accessible at all times.

1) Stairs shall be in accordance with 7.2.2.2.1

Observation determined two (2) of four (4) exit stairs had obstructions that reduced the clear width of the stairs to less than 44 inches.

a) A fixed heater was located in the southeast exit stair that reduced the width of the stairs to 40 inches.

b) A fixed heater was located in the east exit stair that reduced the width of the stairs to 36 inches.

2) 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.

Observation determined the north, northeast and east exterior exits transversed the lawn to get to a public way.

3) 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. 7.2.1.4.4.

Observation determined the door to Storage Room 116 opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

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

The deficiency affected access to the means of egress throughout the facility.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1½-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction. 7.9.3

Review of records indicated the facility failed to conduct annual 1½-hour tests on the emergency battery pack lights throughout the facility.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

Drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. 18.7.1.2

The facility failed to conduct fire drills as required.

Fire drill records review determined the facility failed to conduct fire drills during the third quarter in the past year.

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

The deficiency affected two (2) of eight (8) drills in the past year.

In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location. Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. NFPA 72 1-5.6

The facility failed to install the fire alarm system in accordance with NFPA 72, National Fire Alarm Code.

Observation determined the fire alarm panel located in the Power Room was not protected with an approved device.

Failure to install the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) fire alarm panel in the facility, which serves the entire building.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 18.3.4.1

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code.

1) System defects and malfunctions shall be corrected. NFPA 72 7-1.1.2

Observation determined the fire alarm panel was indicating a trouble condition for the lower heat detector in the Boiler Room that had failed and had not been repaired or replaced at the time of the survey.

2) System defects and malfunctions shall be corrected. NFPA 72 7-1.1.2

Record review indicated the fire alarm failed to transmit the alarm to emergency forces when tested in July 2015 and had not been repaired at the time of the survey.

3) 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 Code. 9.6.1.4

There was no record of the required fire alarm inspection and testing available.

Failure to maintain, inspect and test the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected numerous tests and components of the complete fire alarm system, which serves the entire facility.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years. NFPA 72 7-3.2.1

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72, National Fire Alarm Code.

There was no record of the required smoke detector sensitivity testing available.

Failure to maintain smoke detectors as required increases the risk of death or injury due to fire.

This deficiency affected the entire building.

Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 18.3.5.1

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:

1) The north Dietary Closet lacked sprinkler coverage.

2) There was no sprinkler coverage above the partial suspended ceilings in the Maintenance Office, Purchasing Office and Boiler Room.

3) The sprinklers in the Power Room, the Boiler Room and the Air Handler Room located south of the Laundry Room were not ordinary-temperature-rated, but were intermediate-temperature-rated. The sprinklers were green color coded which is an indication of an intermediate-temperature-rating. These sprinklers are to be used only when the maximum ceiling temperature exceeds 100°F but does not exceed 150°F.

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 six (6) of numerous areas in the facility.

Automatic sprinkler systems are continously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Record review and observation determined:

1) Automatic sprinkler system inspection and test records indicated the last inspection and test of the automatic sprinkler system was conducted on 08/15/2013, exceeding the required annual and quarterly inspection and testing requirements.

2) No record of the required annual back flow preventer test was available.

3) There were tiles missing from the suspended ceilings throughout the building that could delay the activation of the sprinkler system.

4) The shower curtain suspended from a ceiling mounted track obstructed coverage of the sprinkler in Patient Room 147.

5) The privacy curtains with no ½ inch mesh suspended from ceiling mounted tracks obstructed coverage of the sprinklers in Patient Rooms 163 and 165.

6) The privacy curtain with less than ½ inch mesh suspended from a ceiling mounted track obstructed coverage of the sprinkler in Patient Room 121.

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 numerous inspections, tests and components of the automatic sprinkler system, which serves the entire facility.

An inspection and servicing of the fire-extinguishing system and listed exhaust hoods shall be made at least every 6 months by properly trained and qualified persons. NFPA 96 11.2.1

The facility failed to inspect and service the fire-extinguishing system as required by NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

There was no record of the required inspection and servicing of the kitchen range hood fire-extinguishing system.

Failure to inspect and service the fire extinguishing system in accordance with NFPA 96 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire extinguishing system for commercial cooking operations in the building.

Portable space-heating devices shall be prohibited in all health care occupancies. Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C). 18.7.8

The facility failed to prevent the use of portable space heating devices in sleeping areas.

Observation determined an electric portable space heater was being used in the Doctor Sleeping Room.

Failure to prevent the use of portable space heating devices in sleeping areas increases the risk of death or injury due to fire.

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

1) All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110 3-5.5.6

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined there was no remote stop switch for the generator located outside of the generator enclosure.

2) The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. NFPA 110 5-3.1

Observation determined the emergency power transfer switches in the boiler room were not provided with battery powered emergency lighting as required.

Failure to provide emergency lighting at the emergency power transfer switches as required increases the risk of death or injury due to fire.

3) Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes. NFPA 110 6-4.1, 6-4.2

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Review of generator test records could not verify that weekly inspections and monthly 30-minute load tests were conducted in the past year.

Failure to inspect and maintain the emergency generator in accordance with 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.

Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. 18.5.1.1, 9.1.2

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined:

1) An extension cord and 3-way adapter were used in place of permanent wiring to provide power to a microwave and toaster in the Dining Room.

2) An extension cord was used in place of permanent wiring to provide power to a refrigerator in the Reporting Room.

3) There were numerous open electrical panels and junction boxes throughout the basement mechanical rooms.

Failure to comply with NFPA 70 increases the risk of death or injury due to fire.

This deficiency affected the entire building.