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Based on the observation during the survey on 11/14/2016, the facility failed to provide continuous illumination at exit discharges. Findings include:

The following stairwell exit discharges were observed with a single light fixture with a single bulb:

1. Stairwell 13
2. Stairwell 17

The deficiency impacted 2 of 3 smoke compartments.
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Review of 2012 NFPA 101, 7.8.1.2

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Based on the observation during the survey on 11/14/2016, the facility failed to provide exit signs per code. Findings include:

The following first floor stairwell exits were observed without an exit sign:

1. Stairwell 13 (has stairs leading to the basement and a door going back onto the first floor)
2. Stairwell 15 (has stairs leading to the basement)

The deficiency impacted 2 of 3 smoke compartments.
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Review of 2012 NFPA 101, 7.10.1.2.1 Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

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Based on the observation during the survey on 11/14/2016, the facility failed to maintain the alcohol-based hand-rub dispensers per code. Findings include:

An alcohol-based hand-rub dispenser in the Soiled Utility Room was observed to be mounted to the side of an ignition source within 1 in. horizontal distance from the ignition source.

The deficiency impacted 1 of 3 smoke compartments.
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Review of NFPA 101, 19.3.2.6

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Based on the observation during the survey on 11/14/2016, the facility failed to maintain a fire extinguisher per code. Findings include:

The 40 lb fire extinguisher across from room 4326 was mounted approximately 6 ft. above the floor.

The deficiency impacted 1 of 3 smoke compartments.
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Review of 2010 NFPA 10, 6.1.3.8.1

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Based on the observation during the survey on 11/14/2016, the facility failed to prevent impediments to the closing of the corridor door and provide a means suitable for keeping the door closed. Findings include:

1. The Family Waiting Room corridor door had a self-closing device on it and the door was observed being held open by a chair. The chair was removed by the staff, but when the surveyor came back by this room the chair was again holding the corridor door open.
2. The positive latching hardware on the Breakroom corridor door was not working.

The deficiency impacted 2 of 3 smoke compartments.
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Review of Form CMS-2786R (10/2016)
Review of 2012 NFPA 101, 19.3.6.3.10 Doors shall not be held open by devices other than those that release when the door is pushed or pulled.
Review of 2012 NFPA 101, 19.3.6.3.5*

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Based on the observation during the survey on 11/14/2016, the facility failed have documentation on the heating elements of the space heater do not exceeding 212°F (100°C).
Findings include:

The Administrator's Office was observed with two portable space-heating devices, one was plugged in and turned on "Hi" under a desk with combustibles. This room was located in an nonsleeping smoke compartment.

The deficiency impacted 1 of 3 smoke compartments.
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Review of 2012 NFPA 101, 19.7.8
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Based on the observation and review of documentation during the survey on 11/14/2016, the facility failed to provide documentation of weekly visual inspections on the three generators. Findings include:

The facility failed to provide documentation of weekly visual inspections on the three generators.

The deficiency impacted 3 of 3 smoke compartments.
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Review of 2010 NFPA 110, 8.4.1
Review of 2010 NFPA 110, 8.3.4
Review of 2010 NFPA 110, 8.3.4.1