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Based on observation and staff interview the facility failed to provide the level of lighting as required by the Life Safety Code, (NFPA 101) 2012 edition section 7.8.1.4. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 07/18/2024, Between 07:00am and 11:00am, it was revealed by observation that the exterior lights for door 4 Exit of the exit discharges had only one bulb for illumination. Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have a patterned impact on the residents within the facility.

Findings include:

On 07/18/2024, Between 07:00am and 11:00am, it was revealed by observation that patient rooms have been converted to storage rooms along the respiratory corridor, these rooms require self-closing devices.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the automatic fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), the Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, section 5.4.1.4, and 5.4.1.4.2. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 07/18/2024, Between 07:00am and 11:00am, it was revealed by observation that there were unsecured fire sprinkler heads that were not protected from being damaged, stored loosely within the spare sprinkler head boxes located by the fire sprinkler riser in the supply storage room on the lower level.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 07/18/2024, Between 07:00am and 11:00am, it was revealed by observation that there was a penetration running from one smoke compartment to another above fire door #5.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire dampers per NFPA 101 (2012 edition), Life Safety Code, section 8.5.5.4.2, and NFPA 105 (2010 edition), Standard for Smoke Door Assemblies and Other Opening Protectives, section 6.5.2, 6.5.11, and 6.5.12. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 07/18/2024, Between 07:00am and 11:00am, it was revealed by a review of available documentation that the facility could not provide a fire damper inspection report.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the electrical system per NFPA 101 (2012 edition), Life Safety Code, section 9.1.2, and NFPA 70 (2011 edition), National Electrical Code, section 406.6. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 07/18/2024, Between 07:00am and 11:00am, it was revealed by observation that there was a missing cover on an electrical junction box in the ceiling above Fire Door #4.

An interview with the Director of Maintenance verified these deficient findings 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, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 07/18/2024, Between 07:00am and 11:00am, it was revealed by observation that there were several electrical appliances plugged into a power strip and/or power strips were plugged into other power strips being used as extension cords in the Respiratory Therapist Office and in the Nurses Break-room.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to store oxygen cylinders per Health Care Facilities Code NFPA 99 (2012 Edition), sections 11.3.2.3, 11.6.5.2 and 11.6.5.3. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:
On 07/18/2024, Between 07:00am and 11:00am, it was revealed by observation that oxygen is being stored in respiratory therapist office that was not secured while not in use.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.