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This Standard is not met as evidenced by:

Based on record review and confirmed by staff, the facility failed to ensure compliance with specific requirements of the 2012 edition of NFPA 101 Life Safety Code (means of egress is in accordance with Chapter 19.2.1.). `

Section 19.2.1 states every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

Section 7.1.1 states means of egress for both new and existing buildings shall comply with this chapter.

Section 7.1.10.1 states the means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Section 7.2.2.4.3 (Projections) states that the design of guards and handrails and the hardware for attaching handrails to guards, balusters , or walls shall be such that there are no projections that might engage loose clothing. Openings in guards shall be designed to prevent loose clothing from becoming wedged in such openings.

Section 7.7.1 states exits shall terminate directly, at a public way or at an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.

Section 7.7.1.1 states yards, courts, open spaces, or other portions of the exit discharge shall be of the required width and size to provide all occupants with a safe access to a public way.

Findings Include:

On 04/11/22 and 04/12/22 , it was noted that the lower level's east side exterior discharge bulkhead was utilized to store ladders.

These ladders were mounted to the buildings exterior and projected more than 17" into the path of egress approximately 38" above the concrete walking surface.

The storage of the ladders in this area creates an obstruction or impediment to full instant use in the case of fire or other emergency, and a potential to engage loose clothing in the event of an actual emergency.

This deficient practice could affect all staff and patients, in the event of an actual emergency situation where evacuation of the area compartment is necessary.

As a result, the facility failed to comply with section 7.1.10.1 requiring egress routes to be continuously maintained free of all obstructions or impediments.

The findings were confirmed by the Director of Maintenance (DOM) and reviewed with the facility's Administrator and DOM during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas/locations are maintained as required.

Section 19.3.2.1 states any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.

Section 19.3.2.1.1 states an automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.

Section 19.3.2.1.2 states where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Section 19.3.2.1.3 states the doors shall be self-closing or automatic-closing.

Section 19.3.6.3.4 states the clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors.


Findings Include:

On 04/11/22 and 04/12/22, during facility tour the following was noted:

1. The Emergency generator room enclosure, equipped with automatic sprinkler system coverage, has unsealed penetrations in the gypsum wallboard ceiling rendering the enclosure less than smoke resistant.

2. The basement level water heater area equipped with automatic sprinkler system coverage, has unsealed penetrations in the gypsum wallboard ceiling rendering the enclosure less than smoke resistant.

The facility failed to maintain compliance with Section 19.3.2.1, Section 19.3.2.1.1, and Section 19.3.2.1.2.

The findings were confirmed by the Director of Maintenance (DOM) and reviewed with the Administrator and DOM during the exit conference.

Based on observation and record review, the facility failed to ensure compliance with NFPA 101, the "Life Safety Code," the 2011 edition of NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems, and NFPA 13, "Standard for the Installation of Sprinkler Systems."

NFPA 101, Section 4.5.8 (Maintenance) states that 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 thereafter be maintained, unless the Code exempts such maintenance.

NFPA 101 section 9.7.5 states that all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, section 5.3.4 states that antifreeze systems shall be tested for the specific gravity and the freezing point of solutions. The solution shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary.

NFPA 13, Section 8.3.3.2 states where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.

Section 8.3.3.3 states where there are no listed quick-response sprinklers in the temperature range required, standard-response sprinklers shall be permitted to be used.

Section 8.3.3.4 states when existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Note: NFPA 13 Section 3.3.6 defines compartment as a space completely enclosed by walls and a ceiling. Each wall in the compartment is permitted to have openings to an adjoining space if the openings have a minimum lintel depth of 8 in. (200 mm) from the ceiling and the total width of the openings in each wall does not exceed 8 ft (2.4 m). A single opening of 36 in. (900 mm) or less in width without a lintel is permitted when there are no other openings to adjoining spaces.

NFPA 13, Section 8.6.3.4.1 states that unless the requirements of 8.6.3.4.2, 8.6.3.4.3, or 8.6.3.4.4 are met, sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

Findings Include:

1. Record review of automatic sprinkler system documentation conducted on 04/11/22 and subsequent building tour conducted during the afternoon hours of 04/11/22 and 04/12/22 revealed the that the antifreeze system(s), that serves the exterior roof adjacent to the courtyard was not properly tested. The annual inspection by the sprinkler vendor did not provide the solution's specific gravity. The vendor stated that the antifreeze solution was "adequate" with no measurement provided for specific gravity.

2. Observations revealed the existence of two (2) standard response sprinkler heads in the ceiling of the basement level adjacent to the water heaters.

3. Two (2) sprinkler heads located in the generator room are approximately 58" on center (oc.).

As a result of the findings the facility is found to be non-compliant with NFPA 25, section 5.3.4, NFPA 13, Section 8.3.3.2, and NFPA 13, Section 8.6.3.4.1

This deficient practice could affect the current residents, as well as an undetermined amount of staff and visitors in the event of an actual fire.

The findings were confirmed by and reviewed with the Administrator and Maintenance Director during the exit interview conference.

This Standard is not met as evidenced by:

Based on observations, the facility failed to ensure compliance with specific requirements of the 2012 edition of NFPA 101 Life Safety Code.

Section 19.3.6.1 states that corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 unless otherwise permitted.

Findings include:

While conducting the facility tour on 04/11/22 and 04/12/22 observations revealed that the clean linen closet and the communications closet, both adjacent to the corridor identified as "Four Corners," have unsealed penetrations on the closet side of their respective corridor wall(s) below the monolithic ceiling .

As a result of the finding the facility is found to be non-compliant with section 19.3.6.4.1.

This was acknowledged by and reviewed with the Administrator and Director of Maintenance (DOM).

Based on observations the facility failed to ensure that all doors protecting corridor openings are in compliance with the 2012 edition of NFPA 101 Life Safety Code.
Section 19.3.6.3.10 which states doors shall not be held open by devices other than those that release when the door is pushed or pulled.

Findings Include:

During the afternoon hours of 04/11/22, between 1:00 P.M. and 4:00 P.M., while conducting the facility tour, the corridor door to the staff break room and the corridor door to the Housekeeping Supply closet were both held open with a wooden floor wedge.
The presence of the floor wedge, at both corridor doors, requires a releasing action (other than a pushing or pulling of the door) to close the door.

As a result of the finding the facility is found to be non-compliant with NFPA 101, Section 19.3.6.3.10.

The finding was confirmed by and reviewed with the facility's Administrator and Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that all required components of the Fire Safety Plans are contained in the Facility's written plans. This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where relocation is required to be utilized.

Based on document review, the facility failed to provide a detailed written fire plan in accordance with the requirements and failed to properly train staff.

Section 19.7.1.8 states employees of health care occupancies shall be instructed in life safety procedures and devices.

Section (19.7.2.1 Protection of Patients) 19.7.2.1.1 states for health care occupancies, the proper protection
of patients shall require the prompt and effective response of health care personnel.

Section 19.7.2.1.2 states that the basic response required of staff shall include
the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

Section 19.7.2.2 (Fire Safety Plan) states a written health care occupancy fire safety plan shall provide for all of 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

Section 19.7.2.3.2 states all health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

Section 19.7.2.3.3 states personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings Include:

On 04/11/22 and 04/12/22, during surveyor document review and staff interview, the following deficient practices were noted:

The facility's fire plan failed to include a floor plan identifying barrier locations and smoke compartments. A floor plan, located in the fire plan and a floor plan located on the corridor wall failed to identify fire barrier locations and compartments.

As a result of the findings the facility is found to be non-compliant with NFPA 101, Section 19.7.2.1.2 (4) and Section 19.7.2.2 (7).

This was confirmed by and reviewed with the Administrator and the Director of Maintenance during the exit interview.

Based on documentation review and confirmed by staff, the facility failed to ensure that fire drills are conducted in accordance with the 2012 edition of NFPA 101 Life Safety Code.

-NFPA 101 Chapter 4 section 4.7.4* states drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

-NFPA 101 Chapter 19 section 19.7.1.4 states fire drills in health care occupancies shall include
the transmission of a fire alarm signal and simulation of emergency fire conditions.

-NFPA 101 Chapter 19 section 19.7.1.6 states drills shall be conducted quarterly on each shift to
familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

-NFPA 101 Chapter 19 section 19.7.1.7 states when drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

NOTE: Due to the inadvisability of quarterly fire drills that move and mass staff together, CMS will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures, and fire protection devices in their assigned area.

Findings Include:

A review of fire drill documentation conducted during the morning hours of 04/12/22 indicated the following.

During the period from 02/15/21 to 04/12/22 a total of 13 fire drills of the 15 fire drills reviewed. The following was noted:

-1st shift (7:00pm-3:00pm) All fire drills conducted during the 7:00am-3:00pm were in compliance.
-2nd shift (3:00pm-11:00pm): 03/31/22 @ 5:30pm, 10/12/21 @ 9:00pm, 06/24/21 @ 5:15pm, 03/23/21 @ 4:18pm.
-3rd shift (11:00pm-7:00am): 02/25/22 @ 5:00am, 10/05/21 @ 3:00am, 06/21/21 @ 4:00am, 03/15/21 @ 3:00am.

The deficient practice is:

-2nd shift (3:00pm-11:00pm): There were no documented fire drills conducted during the 1st, 3rd quarters of 2021.
-3rd shift (11:00pm-7:00am): There were no documented fire drills conducted during the 3rd quarter of 2021.

As a result of the findings the facility failed to ensure compliance with NFPA 101 Chapter 19 section 19.7.1.6

This deficient practice could affect all current residents, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where the fire drill procedures are required to be utilized.

The findings were confirmed by and reviewed with the Administrator and Maintenance Director during the exit interview conference.