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Based on observation and staff interview, the facility failed to arrange exits in accordance with NFPA 101. The findings were:

Observation on 03-15-2017 at 4:40 PM located at the North East corridor adjacent to Laboratory and Radiology corridor revealed an exit sign above an exterior door. Further observation revealed that beyond the exterior door was a courtyard and that there was no exit to the public way. Once in the courtyard a person would have to re-enter the building at a different location to exit. Interview with the Facility Maintenance Staff at the time of observation indicated they were unaware of the requirement. The ability to leave and then re-enter the building raises a risk of harm for that person due to fire situations.

Ref:
2012 NFPA 101 Sections - 19.2.7 and 7.7.1.11

Based ob observation and staff interview, the facility failed to provide exit signs in accordance with NFPA 101. The findings were:

Observation on 03-15-2017 at 3:24 PM located through the means of egress from the kitchen into the nursing home revealed that there was an exit sign to the North. This sign indicated that an exit access was located to the right (Chevron arrow to the right). Further observation revealed that there was not an exit access to the right as indicated by the exit sign. Interview with the Facility Maintenance Staff at the time of observation acknowledged that there should be no directional indication on the sign because the intent is to travel straight through. Failure to provide correct exit signs may trap, or slow egress out of the building.

Ref:
2012 NFPA 101 - Section 19.2.10.1

Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with NFPA 101. The findings were:

Observation on 03-15-2017 at 4:52 PM located at the laboratory revealed that the door into the lab from the corridor did not have a self closing device. Further observation revealed that the facility keeps this door open as it is a waiting area for patients. Interview with the Facility Maintenance Staff at the time of observation indicated they were unaware of the requirements. Failure to close hazardous areas to the corridors is an increased risk in fire development that may spread through out the facility.

Ref:
2012 NFPA 101 - Sections 19.3.2.1

Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler systems are installed in accordance with NFPA 13. The findings were:

Observation on 03-15-2017 at 4:35 PM in the X-ray room revealed a sprinkler head that was obstructed by a x-ray machine. The x-ray machine was mounted to a track system. Further observation revealed that track system bypassed the sprinkler head. When the X-ray equipment was positioned under or beside the sprinkler head it was clear that the sprinkler became obstructed. Once the sprinkler head was obstructed no other sprinkler head could make up the coverage for the obstructed sprinkler head. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the x-ray machine obstructed the sprinkler head and that there was no other coverage for the obstructed head. Failure to provide adequate coverage of the sprinkler system could result in harm to individuals and increased damage to the building.

Ref:
2012 NFPA 101 - Sections 19.3.5.1 and 9.7
2010 NFPA 13 - Section 8.11.5.3.1

Based on observation and staff interview, the facility failed to inspect portable fire extinguishers in accordance with NFPA 10. The findings were:

1. Observation on 03-15-2017 at 3:35 PM located in the kitchen revealed a K type portable fire extinguisher that had been missing monthly inspections. Further observation revealed that the missing monthly inspections were January 2017 and February 2017. A portable fire extinguisher is the first line of defense and if there are missing monthly checks it could result in the fire extinguisher not operating correctly due to overcharge or undercharge of the extinguisher. Interview with the Facility Maintenance Staff at the time of observation indicated that they had forgotten about this fire extinguisher.

2. Observation on 03-15-2017 at 3:46 PM located in the mechanical room revealed a fire extinguisher placed on the floor. Further observation revealed that extinguisher was not mounted or secured. A portable fire extinguisher is the first line of defense and if the extinguisher is not mounted properly as required in the code it could delay the amount of time to access the extinguisher.

Ref:
2012 NFPA 101 - Section 19.3.5.12

Based on observation and staff interview, the facility failed to provide corridor doors in accordance with NFPA 101. The findings were:

1. Observation on 03-15-2017 at 4:35 PM located at the X-ray and CT room doors to the corridor revealed that both sets of doors had sequential closing devices and when tested the doors failed to close smoke tight and left approximately 1 inch gap into the rooms from the corridor. Interview with the Facility Maintenance Staff at the time of observation indicated that the were unaware of the requirement. Failure to provide smoke resistant doors could result in the spread of smoke during a fire situation.

Ref:
2012 NFPA 101 - Section 19.3.6.3.1

2. Observation on 03-27-2017 at 5:15 PM located at the exit corridor from the radiology department to the rural clinic revealed a set of doors that were not labeled as fire rated. Further observation revealed that the door frame was not labeled as fire rated and that the facility wanted these doors to be the separation point between the hospital and the rural clinic. Interview with the Facility Maintenance Staff at the time of observation indicated they were not sure why the labels were missing. Interview with the CEO at the time of observation indicated that they wanted their 2 hour fire separation at that point and acknowledged that they failed to provide that separation with the missing fire labels on the doors.

Ref:
2012 NFPA 101 - Sections 19.3.6.3.14, 8.3, and 8.3.3.2.3

Based on observation and staff interview, the facility failed to provide smoking signs in accordance with NFPA 101. The findings were:

Observation on 03-15-2017 at 3:35 PM at the main entrance door and at other major entrances, revealed that the facility did not provide smoking signs. Further observation revealed that the facility did not provide secondary signs with the language that prohibits smoking or the international symbol for no smoking. Interview with the Facility Administrator at the time of observation indicated that the facility prohibits smoking in the facility and on the grounds, but that they were not aware of signage requirement at the major entrances. Failure to provide smoking signs may result in an individual bringing lit cigarettes into the facility and may start a fire due to the oxygen enriched environment.

REF:
2012 NFPA 101-Sections 18.7.4