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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 Men's Public Restroom on first floor near the Main Entrance.
b) The corridor door to the Women's Public Restroom on first floor near the Main Entrance.

The deficiency affected two (2) of numerous corridor doors in the means of egress throughout the facility.

2) 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.

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

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

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

The 2010 Standards for Accessible Design generally limit the protrusion of wall-mounted objects into corridors to no more than 4 inches from the wall when the object's leading edge is located more than 27 inches, but not more than 80 inches, above the floor.

Observation determined a wall-mounted water fountain in the corridor on the first floor near the Nurses Station extended 19" from the wall. The leading edge of the water fountain was higher than 27" above the floor.

This deficiency affected one (1) of four (4) exit corridors in the means of egress.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

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

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 and east exterior exits traversed the lawn to get to a public way.

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

The deficiency affected two (2) of four (4) exits from the facility.

The facility failed to ensure hazardous areas were separated from other areas with self-closing doors.

Observation determined the corridor door to the Purchasing Room lacked a self-closing device.

Failure to ensure hazardous areas were separated from other spaces by self-closing, latching doors increases the risk of death or injury due to fire.

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

The facility failed to test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems.

On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. 7.2.1

At a minimum, this quick check or inspection shall include verification of the following:

1) The extinguishing system is in its proper location.
2) The manual actuators are unobstructed.
3) The tamper indicators and seals are intact.
4) The maintenance tag or certificate is in place.
5) No obvious physical damage or condition exists that might prevent operation.
6) The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range.
7) The nozzle blowoff caps, where provided, are intact and undamaged.
8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated. 7.2.2

Review of documentation and interview with staff determined the monthly inspections of the wet chemical extinguishing system in the Kitchen had not been completed in the past year. An outside company did conduct semi-annual inspections of the system.

Failure to conduct monthly inspections of the wet chemical extinguishing system increases the risk of injury or death due to fire.

This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.

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

The facility failed to test the fire alarm system as required.

Review of documentation determined device test results (alarm initiating, supervisory alarm initiating, and notification) did not provide an itemized list with the device type, address, location, and test result as required.

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

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined smoke detectors throughout the facility were mounted on the ceiling within 36 in. of an air diffuser.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected numerous smoke detectors in the facility.

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) Numerous areas in the Medical Records Room lacked sprinkler coverage between the shelves. Shelves extended to within 4 inches of the ceiling.

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

2) Sprinklers in high-temperature zones shall be high-temperature classification, and sprinklers in intermediate-temperature zones shall be intermediate-temperature classification. NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2)

NFPA 13 requires high-temperature-rated sprinklers within a 7 ft. radius cylinder extending 7 ft. above and 2 ft. below horizontal discharge unit heaters.

One (1) sprinkler in the Ambulance Garage was installed within 7 ft. of a horizontal discharge unit heater and was not high-temperature-rated. Three (3) sprinklers in the Ambulance Garage were installed between 7 ft. and 20 ft. from a horizontal discharge heater and were not intermediate-temperature rated.

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

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

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 4.1.4.1

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 observation determined:

1) The control valves and the gauges of the automatic sprinkler system had not been inspected monthly.

2) Quarterly flow tests of the automatic sprinkler system were not completed as required. Records did not indicate flow tests were conducted during the fourth quarter of 2018 and the first and second quarters of 2019.

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.

The facility failed to provide a fire safety plan as required.

A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
19.7.2.2

Observation and policy review determined the fire safety plan did not provide for the emergency phone call to fire department as required.

Failure to provide a fire plan as required increases the risk of death or injury due to fire.

The deficiency affected the required fire safety plan for the entire facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined fire drills did not include the simulation of an emergency phone call to the fire department.

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

The deficiency affected twelve (12) of twelve (12) drills in the past year.

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities.

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

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.