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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. 7.2.1.4.3.1

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

Observation determined numerous corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

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 numerous corridor doors in the means of egress throughout the facility.

Note: The deficiency was corrected before the end of this survey.

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. 7.2.1.4.3.1

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

Observation determined numerous corridor doors throughout the facility opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

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 numerous corridor doors in the means of egress throughout the facility.

Note: Corridor doors observed in this deficiency were corrected prior to the exit of the survey.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. 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, A.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 numerous smoke detectors throughout the facility were installed within 36 in. of an air supply diffuser or return air opening.

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

This deficiency affected numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Note: The deficiency was corrected before the end of this survey.

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 numerous smoke detectors throughout the facility were installed within 3 ft. of an air supply diffuser or air return vent.

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

This deficiency affected numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Note: Smoke detectors observed in this deficiency were corrected prior to the exit of the survey.

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. 4.6.12

1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification. NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2)

Observation determined two (2) sprinklers in the Receiving Garage installed within 7 ft. of unit heaters were not high-temperature-rated. NFPA 13 requires high-temperature-rated sprinklers within a 7 ft. radius cylinder extending 7 ft. above and 2 ft. below horizontal discharge unit heaters.

2) Sprinklers in walk-in type coolers and freezers with automatic defrosting shall be of the intermediate-temperature classification or higher. NFPA 13 8.3.2, 8.3.2.5(10).

Observation determined two (2) sprinklers in the walk-in freezer located in the Kitchen were of ordinary-temperature classification. The walk-in freezer was equipped with an automatic defrosting feature.

3) A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas except where specific sections of NFPA 13 permit the omission of sprinklers. NFPA 13 4.1

Observation determined the following areas lacked sprinkler coverage:

a) The Nursery Housekeeping Closet.

b) The Nursery Electrical Closet.

c) The Pharmacy Closet.

d) The North OR Dictation Room.

e) The South OR Dictation Room.

f) X-Ray Room B.

g) The corridor by X-Ray Room B.

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

This deficiency affected nine (9) of numerous areas in the facility. The automatic sprinkler system serves 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 complete coverage for all portions of the building.

1) Sprinklers in walk-in type coolers and freezers with automatic defrosting shall be of the intermediate-temperature classification or higher. 19.3.5.1, 9.7.1.1(1), NFPA 13 8.3.2, 8.3.2.5(10).

Observation determined sprinklers in two (2) walk-in freezers located in the Kitchen were of ordinary-temperature classification. The walk-in freezers were equipped with an automatic defrosting feature.

2) Observation determined a walk-in freezer located in the Dietary Storage Room lacked sprinkler coverage inside the freezer.

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

This deficiency affected two (2) of numerous rooms in the facility. The automatic sprinkler system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 5.1.1.2

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review and interview with staff determined the control valves and the gauges of the automatic sprinkler system had not been inspected monthly.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 5.1.1.2

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Review of documentation and interview of staff determined the monthly required inspections of the automatic sprinkler system were not conducted.

Inspections include:
1) Inspect gauges of wet system.
2) Inspect control valves.

This deficiency affected two (2) of numerous inspections and tests of the automatic sprinkler system. The automatic sprinkler system serves the entire facility.

Failure to inspect and test the automatic sprinkler system in accordance with NFPA 25 increases the risk of injury or death due to fire.