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Based on observation, interview, and document review, the provider failed to meet the minimum construction standards of the 2012 Life Safety Code (LSC) (incomplete NFPA 13 sprinkler system installation). Findings include:

1. Observation on 7/16/19 revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 12/10/14 confirmed the above condition.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to provide egress doors as required at six of eight exit door locations (main lobby entrance, main lobby handicap entrance, break area exit, freight room exit, clinic front door, and clinic rear door). Findings include:

1. Observation beginning at 1:30 p.m. on 7/16/19 revealed the lobby had two main entrance (exit) doors that were equipped with magnetic locks. The doors also had motion sensor devices mounted above them. Interview with the manager of plant operations at the time of the observation revealed the locks were controlled by a timer to engage after hours. He stated the motion sensors released the magnets when the doors were approached from the interior of the lobby. He added the door magnets would release upon activation of the fire alarm as well. The doors were determined to be access control locks. Access control magnetic locks in accordance with 7.2.1.6.2 would be permitted.

NFPA 101, Section 7.2.1.6.2(3) Door locks shall be arranged to unlock in the direction of egress from a manual release device complying with all of the following criteria:
(a) The manual release device shall be located on the egress side, 40 to 48 inches vertically above the floor, and within 60 inches of the secured door openings.
(b) The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT.
(c) When operated, the manual release device shall result in direct interruption of power to the lock -- independent of the locking system electronics -- and the lock shall remain unlocked for not less than 30 seconds.

NFPA 101, Section 7.2.1.6.2(4) Activation of the building fire-protective signaling system shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset.

NFPA 101, Section 7.2.1.6.2(5) The activation of manual fire alarm boxes that activate the building fire-alarm signaling system specified in 7.2.1.6.2(4) shall not be required to unlock the door leaves.

NFPA 101, Section 7.2.1.6.2(6) Activation of the building automatic sprinkler or fire detection system shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset.

The two sets of lobby exit doors were not provided with the required manual release button adjacent to the doors and labeled "Push to exit."

Interview with the manager of plant operations at the time of the observation confirmed that condition. He stated of the remaining four sets of exit doors break area, freight, clinic front, and clinic rear were also equipped with access control magnetic door locks.

Failure to provide egress doors as required increases the risk of death or injury due to fire.

The deficiency affected 100% of the building occupants.

Ref: 2012 NFPA 101 Section 19.2.2.2.4(3), 7.2.1.6.2

Based on observation, interview, and document review, the provider failed to maintain conforming exit stairways in five randomly observed locations (south stairs, northwest stairs, east stairs, west stairs, and the north stairs). Findings include:

1. Observation on 7/16/19 at 2:15 p.m. revealed handrails were not provided on both sides of the stairwell in the south stairs and at the top of the landing of the northwest stairs. The south stairs were 39 inches wide. The northwest stairs were 50 inches wide.

2. Observation on 7/16/19 at 2:30 p.m. revealed the interior landing in front of the exterior exit door in the south stairs sloped up approximately six inches to the door threshold.

3. Observation on 7/16/19 between 2:30 p.m. and 3:00 p.m. revealed the following door openings into stair enclosures reduced the landing widths to less than 22 inches:
* The door opening into the first floor, east stairs reduced the landing to 15 inches.
* The door opening into the first floor, west stairs reduced the landing to 19 inches.
* The door opening into the first floor, north stairs reduced the landing to 17 1/2 inches.

4. Interview with the director of plant operations at the time of the above observations confirmed those findings. Review of previous survey documents dated 12/10/14 confirmed the above findings.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain one of two hazardous areas (boiler room) in the lower level as required by having unsealed openings in fire-rated walls. Findings include:

1. Observation at 2:15 p.m. on 7/16/19 revealed the boiler room in the lower level had penetrations of the one-hour, fire-rated wall above the corridor door by three large water pipes and three electrical conduits. Those penetrations must be sealed with an approved fire-stop material such as intumescing fire caulk.

Interview with the manager of plant operations at the time of the observation confirmed those findings.

The deficiency affected one of numerous requirements for hazardous rooms.

Based on observation, interview, and document review, the provider failed to meet the minimum construction standards of the 2012 Life Safety Code (LSC) (incomplete NFPA 13 sprinkler system installation). Findings include:

1. Observation at 3:45 p.m. on 7/16/19 revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system.

Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 12/10/14 confirmed the above findings.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight characteristics of one randomly observed door (kitchen/nutrition room on the patient wing) as required. Findings include:

1. Observation at 10:00 a.m. on 7/17/19 revealed the kitchen/nutrition room on the second floor patient wing had a solid bonded wood door equipped with a closer. The door was standing ajar when checked during the survey. Testing of the door at the time of the observation revealed the door would not close and latch with the closer operation or by manually pulling the door to the frame. The door was binding at the top of the frame.

Interview with the manager of plant operations at the time of the observation confirmed that finding.

The deficiency affected one of numerous requirements for corridor doors and corridor smoketight characteristics and had the potential to affect 100% of the occupants of the smoke compartment.