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Based on record review the facility failed to plan and implement a provision of subsistence needs for the staff and the residents. This affects all occupants in the facility.

Findings include:

1. Review of the EP plan, policies, and procedures on 9/19/2023, reflected the facility's emergency plan lacked policies and procedures for subsistence needs for staff and residents, particularly specific policies describing how alternate sources of energy will maintain proper temperatures, emergency lighting, keep sprinkler and alarm systems online, as well as sewage and waste disposal in the event of a loss of water.

Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3, 7.2.1.5.10, and 7.2.1.6. Facilities can only lock doors and gates in the case of clinical need such as a special care unit.

Findings include:

1. During an observation on 9/19/23 at 11:33 a.m., the ER suite was inspected. There was an illuminated exit sign guiding occupants into the ER from the entry foyer. The doors were locked via magnetic locks, with a "badge-in" type security system. There was not any delayed egress programmed into the doors to the ER. The access-controlled egress system, was complete inside the ER to let occupants out of the suite.

Whatever type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress, the facility must then apply all the features the code requires in NFPA 101-2012 Section 7.2.1.6. The locked doors in the lighted path of egress must also unlock and be open to occupants in the event the sprinkler or fire detection systems are activated.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.1.10.2.1, and Section 7.10.1.2.2.

Findings include:

1. During an observation on 9/19/23 at 11:43 a.m., the exit signage around the corridors of the procedure room were inspected. There were no exit signs guiding occupants from the foyer of the procedure room. There was several doors which could be confused as a way out of the area. It would not be obvious in times of darkness, smoke, or panic.

Based on observation, the facility failed to ensure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 9/19/23 at 12:15 p.m., the room 5 was found to be used as a storage room. It was over 50 square feet and the corridor door lacked a self-closing device.

2. During an observation on 9/19/23 at 12:26 p.m., the storage room across from room 11 was inspected. The room contained a lot of combustible items in storage. The room was over 50 square feet and lacked the required self-closer on the door.

3. During an observation on 9/19/23 at 12:30 p.m., the soiled utility room on the hospital side was inspected. The room lacked the required self-closer on the corridor door.

4. During an observation on 9/19/23 at 12:33 p.m., the laundry room was inspected. The laundry was over 100 square feet and lacked the required self-closer on the corridor door.

5. During an observation on 9/19/23 at 12:35 p.m., the hospital EVS storage room lacked a self-closing device. The room is over 50 square feet.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 9/19/23 at 12:23 p.m., the corridor near room 12 was inspected. There was an ABHR station mounted over an outlet.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2. and the facility failed to maintain proper distances between sprinkler heads, in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.3.4.1.

Findings Include:

1. During an observation on 9/19/23 at 11:51 a.m., the X-ray room was inspected. A ceiling mounted rail system for the x-ray unit was observed, obstructing a sprinkler head. The head was within 12 inches of the rail, and the rail was lower than the deflector on the sprinkler head.

2. During an observation on 9/19/23 at 12:33 p.m., the laundry room was inspected. There were two sprinkler heads in the room which were only 4 feet apart. Sprinkler heads must be a minimum of 6 feet apart.

Based on record review, the facility failed:

a) to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2.;

b) to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 14.2.

c) to make records available for all inspections, tests, and maintenance of the facilities wet and dry sprinkler system per NFPA 25-2011, Section 4.3.1.

d) to maintain the monthly gauge readings on all of the sprinkler risers per NFPA 25-2011, Sections 5.2.4.1 and 5.2.4.2;

e) to ensure spare sprinklers were available in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5,

f) to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition Section 5.2.1.1.1.,

Findings include:

1. During a review of facility records and observation of the standpipe vendor tags on 9/19/2023, the facility failed to ensure the quarterly sprinkler inspections had been completed. There were no documented inspections for the third and fourth quarters of 2022, and the first quarter of 2023.

2. During a review of the facility inspection records on 9/19/2023, it was noted that the facility lacked documentation of the five- year inspection reports for the facilities wet and dry sprinkler systems.

3. During a review of the facility inspection records on 9/19/23, it was noted the facility lacked any documentation that the weekly and monthly gauge pressure readings had been completed.

4. During an observation 9/19/23 at 12:10 p.m., the spare sprinkler head box at the stand pipe was found to be missing directional replacement sprinkler heads. The facility utilized some directional heads on the system, they did not have any spares for the type of head being utilized.

5. During an observation on 9/19/23 at 12:19 p.m., the hospital linen storage closet was inspected. The drop-down sprinkler head in the room was found to be painted around the edges of the cover. This could possible interfere with the ability to properly engage during a fire.

Based on observation, and record review, the facility failed to ensure timely (every 5 years) hydrostatic testing for the K type extinguisher, located in the kitchen, in accordance with NFPA 101-2012, Section 9.7.4.1 and NFPA 10-2010, Section/Table 8.3.1 Hydrostatic Test Intervals for Extinguishers.

Findings include:

1. During an observation on 9/19/23 at 11:12 a.m., the portable K tank in the kitchen was inspected. The tank had not had a hydrotest since October of 2017. The tank was due for the hydrotest in October of 2022. Review of facility records revealed the annual inspection of the facility fire extinguishers was completed in October of 2022, but the vendor failed to perform the hydrotest of the K tank in the kitchen.

Based on observation, the facility failed to ensure the installation of a direct vent fireplace met all regulatory criteria in accordance with NFPA 101 2012 Edition, Section 19.5.2.3 and 9.8.

Findings include:

1. During an observation on 9/19/23 at 12:39 p.m., the cafeteria was inspected. There was a direct vent gas fireplace installed in the room. There was no electronically supervised carbon monoxide detector installed in the room.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6 and 19.7.2.2.

Findings include:

1. During a review of facility fire drills on 9/19/2023, it was determined the facility had only documented one fire drill between July of 2022 and July of 2023. The fire drill that was completed was done in the day shift of the second quarter of 2023.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

Findings include:

1. Review of the fire safety maintenance records on 9/19/2023, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

Based on observation, the facility failed to ensure an emergency stop button for the generator was installed in accordance with NFPA 110, 2010 Edition, Section 5.6.5.6., and failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 110, Section 8.3.8.

Findings include:

1. During an observation on 9/19/23 at 11:07 a.m., the generator was inspected. The generator providing emergency power did not have a remote manual stop outside of the housing of the prime mover or elsewhere on the premises, even while being located outside.

2. Review of the emergency generator inspection records on 9/19/23, showed the annual diesel fuel supply quality test was not conducted within the last year.