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Based on observation, interview, policy review and record review, the facility failed to have it's fire safety planning and training address the relocation of wheeled equipment in the corridors during a fire or similar emergency (K232). The facility failed to ensure each path of egress was marked with an exit sign (K293). The facility failed to maintain the stated protection level surrounding its vertical openings (K311). The facility failed to ensure doors to hazardous areas were on a self closer (K321). The facility failed to ensure it's alarm system was tested in accordance with NFPA 72, 2010 edition (K345). The facility failed to ensure it's sprinkler system was inspected in accordance with NFPA 25 (K353). The facility failed to ensure doors protecting corridor openings had a means suitable for keeping them closed (K363). The facility failed to maintain the protective construction of its smoke barriers (K372). The facility failed to ensure doors in smoke barriers self closed (K374). The facility failed to inspect the function of the fire dampers within the heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8 of 90A, 2012 edition and therefore 19.4.1.1 in NFPA 80 (K521). The facility failed to ensure each fire drill included the transmission of the fire alarm signal (K712). The facility failed to ensure mobile trash collection receptacles were kept in a room protected as hazardous (K754). The facility failed to have it's systems assessed for risk in such a way as to have them meet the descriptions in NFPA 99, 2012 edition, 4.1 (K901). The facility failed to ensure it acted upon it's annual medical gas and vacuum system inspection report in accordance with NFPA 99, 2012 edition, 5.1.14.2.2 (K907). The facility failed to comply with NFPA 99, 2012 edition, 6.4.1.1.17 (K916). The facility failed to comply with NFPA 99, 2012 edition, 15.13 (K933). The cumulative effect of these systemic practices resulted in the facility's inability to ensure patients receiving services from the facility would be protected in the event of a fire.

Based on observation, interview, and record review, the facility failed to ensure it complied with the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association, 101. This had the potential to affect all patients receiving services from the facility.

Findings include:

K232 Failed to have its fire safety planning and training address the relocation of wheeled equipment in the corridors during a fire or similar emergency.

K293 Failed to ensure each path of egress was marked with an exit sign.

K311 Failed to maintain the stated protection level surrounding its vertical openings.

K321 Failed to ensure doors to hazardous areas were on a self closer.

K345 Failed to ensure its alarm system was tested in accordance with NFPA 72, 2010 edition.

K353 Failed to ensure its sprinkler system was inspected in accordance with NFPA 25.

K363 Failed to ensure doors protecting corridor openings had a means suitable for keeping them closed.

K372 Failed to maintain the protective construction of it's smoke barriers.

K374 Failed to ensure doors in smoke barriers self closed.

K521 Failed to inspect the function of the fire dampers within the heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8 of 90A, 2012 edition and therefore 19.4.1.1 in NFPA 80.

K712 Failed to ensure each fire drill included the transmission of the fire alarm signal.

K754 Failed to ensure mobile trash collection receptacles were kept in a room protected as hazardous.

K901 Failed to have it's systems assessed for risk in such a way as to have them meet the descriptions in NFPA 99, 2012 edition, 4.1.

K907 Failed to ensure it acted upon it's annual medical gas and vacuum system inspection report in accordance with NFPA 99, 2012 edition, 5.1.14.2.2.

K916 Failed to comply with NFPA 99, 2012 edition, 6.4.1.1.17.

K933 Failed to comply with NFPA 99, 2012 edition, 15.13.