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The facility failed to ensure the corridor doors were provided with automatic latching hardware to keep the doors closed.

Observation determined:

1) The corridor door to Patient Room 104 did not latch into the door frame.
2) The corridor door to the Trash Room near the Lobby did not latch into the door frame. The Trash Room was 41 square feet.
3) The second leaf of the corridor door to the Casemix Room was not equipped with automatic latching hardware.
Failure to equip corridor doors with automatic latching hardware capable of keeping the door closed increases the risk of injury or death.

This deficiency affected three (3) of numerous doors in the building.

The facility failed to separate hazardous areas from other spaces with smoke resistive partitions and self-closing door assemblies.

Observation determined:1) The corridor door to the Dietary Store Room in the basement was not equipped with a self-closing device.
2) The corridor door to the Linen Supply Closet in the Southwest Wing did not self-close and latch into the door frame.
3) The corridor door to the Soiled Linen Room on the first floor near the Lobby did not self-close and latch into the door frame.

Failure to ensure hazardous areas are equipped with doors which are self-closing increases the risk of injury and death.This deficiency affected three (3) of fourteen (14) hazardous areas.

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. 7.2.1.4.4.

The facility failed to ensure exit access was readily accessible at all times. Observation determined the following doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened:

1) The corridor door to the Housekeeping Closet in the basement by the elevator.
2) The corridor door to the area under the south stairway in the basement.
3) The double set of corridor doors to the Casemix Room on the first floor.Failure to ensure exit access was readily accessible at all times increases the risk of death or injury due to fire. This deficiency affected four (4) of numerous doors in the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1, 9.6.1.4, NFPA 72 7-3.2

The facility failed to test and maintain the fire alarm system as required by NFPA 72, National Fire Alarm Code.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The most current fire alarm system batteries load voltage test was conducted on 11/12/2015 during the annual inspection by an outside company. No other record of a load voltage test of the fire alarm system batteries was available.

Failure to 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 two (2) load voltage tests of the fire alarm system batteries in the past year. The fire alarm system serves the entire 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. NFPA 72 A-2-3.5.1

The facility failed to ensure smoke detectors were installed in accordance with NFPA 72, National Fire Alarm Code.

Observation determined smoke detectors were located less than three (3) feet from direct airflow from air supply diffusers and ceiling fans throughout the building. Failure to install smoke detectors in accordance with National Fire Alarm Code requirements increases the risk of injury or death. This deficiency affected the entire 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 the concealed space under the west stairway lacked sprinkler coverage. The facility was using the area for storage of combustible materials.

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

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

The facility failed to maintain the means of egress free of obstructions or impediments to full instant access in case of fire.

Observation determined:
1) Wheelchairs, patient lifts, and walkers were being stored in the exit corridors throughout the facility.
2) Portable commodes were being stored in the northwest stairway.

Failure to maintain exit access free of obstructions increases the risk of injury or death due to fire.

This deficiency affected the entire building.

Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall therefore be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 4.6.12.1

Existing life safety features obvious to the public, if not required by the code, shall be either maintained or removed. 4.6.12.2

The facility failed to test and maintain battery powered smoke detectors throughout the facility.

Record review and interview of staff determined the battery powered smoke detectors throughout the Wellness Center were not being tested weekly as suggested by the manufacturer.

Failure to test and maintain life safety devices increases the risk of injury or death due to fire.

This deficiency affected the entire Wellness Center.

A remote annunciator, storage battery powered, shall be provided in a location readily observed by operating personnel at a regular work station. NFPA 99 3-4.1.1.15 The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities. 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.

The facility failed to ensure the corridor doors were provided with automatic latching hardware to keep the doors closed.

Observation determined:

1) The corridor door to Patient Room 104 did not latch into the door frame.
2) The corridor door to the Trash Room near the Lobby did not latch into the door frame. The Trash Room was 41 square feet.
3) The second leaf of the corridor door to the Casemix Room was not equipped with automatic latching hardware.
Failure to equip corridor doors with automatic latching hardware capable of keeping the door closed increases the risk of injury or death.

This deficiency affected three (3) of numerous doors in the building.

The facility failed to separate hazardous areas from other spaces with smoke resistive partitions and self-closing door assemblies.

Observation determined:1) The corridor door to the Dietary Store Room in the basement was not equipped with a self-closing device.
2) The corridor door to the Linen Supply Closet in the Southwest Wing did not self-close and latch into the door frame.
3) The corridor door to the Soiled Linen Room on the first floor near the Lobby did not self-close and latch into the door frame.

Failure to ensure hazardous areas are equipped with doors which are self-closing increases the risk of injury and death.This deficiency affected three (3) of fourteen (14) hazardous areas.

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. 7.2.1.4.4.

The facility failed to ensure exit access was readily accessible at all times. Observation determined the following doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened:

1) The corridor door to the Housekeeping Closet in the basement by the elevator.
2) The corridor door to the area under the south stairway in the basement.
3) The double set of corridor doors to the Casemix Room on the first floor.Failure to ensure exit access was readily accessible at all times increases the risk of death or injury due to fire. This deficiency affected four (4) of numerous doors in the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1, 9.6.1.4, NFPA 72 7-3.2

The facility failed to test and maintain the fire alarm system as required by NFPA 72, National Fire Alarm Code.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The most current fire alarm system batteries load voltage test was conducted on 11/12/2015 during the annual inspection by an outside company. No other record of a load voltage test of the fire alarm system batteries was available.

Failure to 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 two (2) load voltage tests of the fire alarm system batteries in the past year. The fire alarm system serves the entire 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. NFPA 72 A-2-3.5.1

The facility failed to ensure smoke detectors were installed in accordance with NFPA 72, National Fire Alarm Code.

Observation determined smoke detectors were located less than three (3) feet from direct airflow from air supply diffusers and ceiling fans throughout the building. Failure to install smoke detectors in accordance with National Fire Alarm Code requirements increases the risk of injury or death. This deficiency affected the entire 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 the concealed space under the west stairway lacked sprinkler coverage. The facility was using the area for storage of combustible materials.

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

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

The facility failed to maintain the means of egress free of obstructions or impediments to full instant access in case of fire.

Observation determined:
1) Wheelchairs, patient lifts, and walkers were being stored in the exit corridors throughout the facility.
2) Portable commodes were being stored in the northwest stairway.

Failure to maintain exit access free of obstructions increases the risk of injury or death due to fire.

This deficiency affected the entire building.

Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall therefore be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 4.6.12.1

Existing life safety features obvious to the public, if not required by the code, shall be either maintained or removed. 4.6.12.2

The facility failed to test and maintain battery powered smoke detectors throughout the facility.

Record review and interview of staff determined the battery powered smoke detectors throughout the Wellness Center were not being tested weekly as suggested by the manufacturer.

Failure to test and maintain life safety devices increases the risk of injury or death due to fire.

This deficiency affected the entire Wellness Center.

A remote annunciator, storage battery powered, shall be provided in a location readily observed by operating personnel at a regular work station. NFPA 99 3-4.1.1.15 The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities. 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.