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Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.3, 8.5.6.5 and 8.5.6.2. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/21/2024, between 0800am and 12:00pm, it was revealed by observation that there was a hold-open device on the fire doors leading out of the Procedure Entrance. This device defeats the self-closing device on the Fire Wall Doors.

An interview with the Maintenance Manager 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 08/21/2024, between 0800am and 12:00pm, it was revealed by observation that there was a penetration running from one smoke compartment to another above doors in the following areas;

1) Above doors to link
2) Above doors area E to Area F
3) Above doors by room F113 Imaging waiting area
4) Above doors at Emergency Room entrance
5) Above doors at entrance to Patient Therapy

An interview with the Maintenance Manager 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 doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 08/21/2024, between 0800am and 12:00pm, it was revealed by review of available documentation the required annual door inspection documentation was not available at the time of the survey.

An interview with the Maintenance Manager 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 doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 08/21/2024, between 0800am and 12:00pm, it was revealed by observation that the following fire doors and/or fire door frames were missing or painted over door rating tags.

1) Fire doors leading to Physical Therapy area.

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

Based on a review of available documentation and staff interview, the facility has failed to provide a complete facility Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 08/21/2024, between 0800am and 12:00pm, It was revealed during documentation review and an interview with the Environmental Services that the utility risk assessment document could not be provided at the time of the survey.

An interview with the Maintenance Manager 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 08/21/2024, between 0800am and 12:00pm, it was revealed by observation that there was a missing cover on an electrical junction box in the ceiling near the Visitors Lounge.

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

Based on a review of available documentation and staff interview, the facility failed to install and maintain generators per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, 6.4.1.1.16.2 and 6.4.1.1.17, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.4.9, 8.4.9.1, 8.4.9.2 and 8.4.9.5.1. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/21/2024, between 0800am and 12:00pm, it was revealed by a review of available documentation of the emergency generator maintenance and testing that the facility could not provide documentation that a 36 month four (4) hour load bank test had been performed.

An interview with the Maintenance Manager 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 08/21/2024, between 0800am and 12:00pm, it was revealed by observation that T size oxygen cylinders stored in the Ambulance Bay that are not in a approved fir rated enclosure.

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