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Based on observation and staff interview, the facility failed to ensure that stairs were maintained free of combustible storage. This deficient practice could slow egress in the stair and increase the fire load inside of an exit enclosure, affecting approximately 11 occupants in 3 of 16 smoke compartments. Facility census was 11 and licensed for 25 at the time of the survey.

Finding are:
Observation and staff interview on 5-16-2023 at 10:45 AM revealed the following:

The stair tower located in the main lobby that connects Basement, 1st Floor, 2nd floor and 3rd Floor contained 3 stored Christmas trees located on the basement level.

During interview on 5-16-2023 at 10:45 AM, Maintenance Staff A confirmed the storage inside the stair enclosure.

Based on observation and staff interview, the facility failed to ensure that there were no obstructions to the fire sprinkler discharge. This deficient practice would obstruct the water spray pattern from the sprinkler system causing water to not reach the point of fire origin allowing fire, smoke and gases to spread affecting approximately 8 occupants in 1 of 16 smoke compartments. Facility census was 11 and licensed for 25 at the time of the survey.

Finding are:
Observation and staff interview on 5-16-2023 at 10:00 AM revealed the following:

A box located on a shelf was less than 18" from an overhead sprinkler located in the 3rd floor Emergency wing food pantry room.

During interview on 5-16-2023 at 10:00 AM Maintenance Staff A confirmed the fire sprinkler obstruction.

Based on observation and staff interview, the facility allowed the use of an extension cord as a substitute for permanent wiring. This deficient practice could cause electrical injury or fire which would affect approximately 10 occupants in 1 of 16 smoke compartments. Facility census was 11 and licensed for 25 at time of survey.

Finding are:
Observation on 5-16-2023 at 9:30 AM revealed the following:

An extension cord was in use to supply power to a Hot Dog warming oven located in the 2nd floor Cafeteria dining wing.

During interview on 5-16-2023 at 9:30 AM, Maintenance Staff A confirmed the use of an extension cord.

Based on observation and staff interview, the facility failed to ensure gas equipment was secured when not in use in 1 of 16 smoke compartments. This deficient practice could cause the potential for rapid fire growth within the room in the event of cylinder falling over, which would have affected approximately 7 occupants. Facility census was 11 and licensed for 25 at time of survey.

Finding are:
Observations on 5-16-2023 at 9:45 AM revealed the following:

One oxygen cylinder located in the 2nd floor MRI wing corridor was free standing and not restrained or in a hand truck.

During interview on 5-16-2023 at 9:45 AM, Maintenance Staff B confirmed that the cylinder was not restrained.

NFPA 99-11.4.3.1.1 2012 edition, Carts and hand trucks for cylinders and containers shall be constructed for the intended purpose, be self-supporting, and be provided with appropriate chains or stays to retain cylinders or containers.