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Based on observation and staff interview, the facility failed to install self-closing devices per NFPA 101 (2012 edition), Life Safety Code, section 19.3.2.1.3 and 19.3.2.1.5. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed by observation that room 531 was being used for storage of combustible supplies and did not have self-closing devices on the door.

An interview with Maintenance Director verified this deficient finding at the time of discovery.

Based on observation, a review of available documentation, and staff interview, the facility failed to install proper protection for cooking equipment per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.5.1, 19.3.2.5.3 (9). This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed by observation that a stove in the Clinic Area did not have a timer, not exceeding 120 minutes, that automatically deactivates the cooktop or range, independent of staff action.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the fire sprinkler systems per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 6.7.4. These deficient findings could have an isolated impact on residents within the facility.

Findings include:

On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed by observation that the main drain valves on the two dry sprinkler systems, and three wet sprinkler systems were not permanently marked with metal or plastic signs secured with corrosion resistant wire or chain.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation, the facility failed to maintain corridor doors per NFPA 101 (2012 edition), Life Safety Code, section 19.3.6.3.5. This deficient finding could have a pattewrened impact on the residents within the facility.

Findings include:

On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed by observations that the doors to patient rooms 112 and 116 did not latch when they were closed.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 04/16/2024 between 09:15 AM and 1:00 PM, it was revealed by a review of available documentation that the facility could not provide a NFPA 99 Risk Assessment for Chapters 5, 6, and 9 at the time of the survey.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, section 10.2.3 and 10.2.4, NFPA 101 (2012 edition), Life Safety Code, section 9.1.2, NFPA 70, (2011 edition), National Electrical Code, section 400.8. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 04/16/2024 between 9:15 AM and 1:00 PM, it was revealed observation there was an extension cord providing power to a charging unit for a mobile computer system in Room 169.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.