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Based on visual observation the facility failed to maintain clear and unobstructed corridors. When items are blocking the egress width of the corridor the building occupants could be delayed in exiting the building. This deficient practice has the potential to affect 6 of 6 residents.


Findings:

During the facility tour on 12/8/22, between the hours of 8:30a-4:30p observation revealed storage in the corridor outside office in sleep study corridor.

Interview with maintenance revealed the facility was not aware of the items in the corridor that was obstructing the egress.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 6 of 6 residents.

Findings:

During the facility tour on 12/8/22, between the hours of 8:30a-4:30p observation revealed no sprinkler coverage in the server room and the sprinkler head in the gift shop storage is painted.


Interview with maintenance revealed the facility was not aware the automatic sprinkler system was not complete.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke and fire from one compartment to the other in the facility. The deficient practice had the potential to affect 6 of 6 patients.


Findings:

During the facility tour on 12/8/22, between the hours of 8:30a-4:30p observation revealed unsealed penetrations in the smoke barriers throughout the facility.

Interview with maintenance revealed the facility was not aware of the unsealed penetrations.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 6 of 6 residents.

Findings:

During the record review on 12/8/22, between the hours of 8:30a-4:30p record review revealed 1 fire drill was conducted during the last 12 months.

Interview with maintenance revealed the facility was not aware fire drills were not being held 1 per shift per qurater.

Portable space heating devices shall be prohibited in all health care occupancies. Unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).
18.7.8, 19.7.8

Based on visual observation the facility failed to assure that portable heating devices were not restricted from use. Since the devices are portable, they can be placed to closely to a combustible ignition source which would result in a fire/smoke emergency. This deficient practice has the potential to affect 6 of 6 residents.

Findings:

During the facility tour on 12/8/22, between the hours of 8:30a-4:30p observation revealed protable space heaters in patient care areas throughout the facility.

Interview with maintenance revealed the facility was not aware that portable space heaters were not allowed within the area containing the resident ' s sleeping rooms.

Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)

Based on visual observation and record review, the facility failed to assure that the hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 6 of 6 residents.

Findings:

During the record review on 12/8/22, between the hours of 8:30a-4:30p observation revealed inspection and testing of non hospital grade receptacles has not been completed with the last 12 months.

Interview with maintenance revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the non hospital grade receptacles.