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

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. (8.9 cm) on each side shall be permitted at 38 in. (96 cm) and below. 7.1.10.1, 7.3.2.2

Observation determined:

1) A fixed heater that was located in the corridor by the west exit door in Smoke Compartment G extended approximately fourteen (14) inches from the corridor wall and protruded into the exit corridor.
2) A fixed heater that was located in the corridor by the north exit door in Smoke Compartment G extended approximately fourteen (14) inches from the corridor wall and protruded into the exit corridor.
3) A fixed heater that was located in the corridor by the east exit door in Smoke Compartment G extended approximately fourteen (14) inches from the corridor wall and protruded into the exit corridor.
4) A water fountain that was located in the corridor by the south exit door in Smoke Compartment C extended approximately ten (10) inches from the corridor wall and protruded into the exit corridor.

The corridor was eight (8) feet wide at all locations.

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

The deficiency affected egress from two (2) of seven (7) smoke compartments in the facility.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) 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

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 located in the Emergency Room and in the corridor by the Maintenance Office were installed within three feet of air supply diffusers, return air openings or ceiling fans.

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

This deficiency affected two (2) of numerous smoke detectors in the facility.

Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than ½ hour. 19.3.6.2.1.

The facility failed to provide corridors separated from use areas by walls with at least ½-hour fire resistance rating.

Observation determined the corridor walls in Smoke Compartment B stopped at the suspended ceilings and did not extend to the roof deck

Failure to separate corridors from use areas by walls with at least ½-hour fire resistance rating increases the risk of death or injury due to fire.

This deficiency affected exit corridors in one (1) of seven (7) smoke compartments in the facility.

The facility failed to provide a documented risk assessment of building systems. NFPA 99, 4.2

Review of documentation and interview of staff determined the facility failed to conduct and document a risk assessment of building systems.

Failure to conduct a risk assessment of building systems increases the risk of injury or death due to fire.

This deficiency affected building systems throughout the entire facility.

Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110. Critical care rooms (Category 1 Room) shall be served only by a Type I EES. General care rooms (Category 2 Room) shall be served by a Type I or Type II EES. A Type I EES serving a critical care room (Category 1 Room) shall be permitted to serve general care rooms (Category 2 Room) in the same facility. NFPA 99, 6.3.2.2.10, NFPA 110, 5.6.5.6, 5.6.5.6.1

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems.

All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. The remote manual stop station shall be labeled.

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

Failure to ensure the emergency generator was in compliance with NFPA 99 and 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 and emergency lighting to the facility.

Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Diesel-powered EPS installations that do not meet the requirements shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. NFPA 99 6.4.4.1.1.4, NFPA 110 8.4.1, 8.4.2, 8.4.2.3

The facility failed to ensure the emergency generator was in compliance with NFPA 99 and NFPA 110.

Review of generator test records did not indicate that the minimum exhaust temperature provided by the manufacturer was achieved and that the monthly exercise of the diesel generator loaded the generator to at least 30% (30 kW) of the nameplate rating. The nameplate rating of the generator was 100 kW. The facility did not perform an annual supplemental load exercise as required when diesel generators are not loaded to 30% of nameplate rating or manufacturer's recommended temperature during the required monthly exercises.

Failure to inspect and maintain the emergency generator in accordance with NFPA 99 and 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.