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Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected, tested and maintained in accordance with the requirements of NFPA 25. Proper maintenance ensures the activation of the sprinkler system will 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 13 of 13 residents.

Findings:

During the facility tour on 2/18-19/2019, between the hours of 8:30a-3:00p observation revealed no sprinkler coverage above the dryers in laundry, painted sprinkler heads in Xray and upright heads used in a pendant application on back hall going towards generator.

Interview with Administrator revealed the facility was not aware of any issues with the automatic sprinkler system.

Based on visual observation the facility failed to assure that the areas open to the corridor were protected in a manner allowed by code. Providing approved protection of the corridor is essential in protecting the corridor in case of a fire or other smoke emergency. The deficient practice had the potential to affect 13 of 13 residents.

Findings:

During the facility tour on 2/18-19/2019, between the hours of 8:30a-3:00p observation revealed a room beside the nurses station open to the corridor.

Interview with Administrator revealed the facility was not aware of the area open to the corridor would allow the transfer of smoke to the corridor.

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 from one compartment to the other in the facility. The deficient practice had the potential to affect 13 of 13 residents.


Findings:

During the facility tour on 2/18-19/2019, between the hours of 8:30a-3:00p observation revealed unsealed penetrations in the barrier between Exam 1 & Exam 2 and the barrier between Zone 1 & 2. Observation also revealed penetrations in the draftstop in the attic above business office area.

Interview with Administrator revealed the facility was not aware of unsealed penetration.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect 13 of 13 residents.

Findings:

During the facility tour on 2/18-19/2019, between the hours of 8:30a-3:00p observation revealed the medication refrigerator located in the nurses station, med room across from nurses station and in therapy office were not plugged into the life safety branch for emergency power. Also observation revealed extension cord and daisy chained power strips were located in the CT Scan, Pharmacy, Lab and Respiratory.

Interview with Administrator revealed the facility was not aware of the electrical issues in the facility.

Based on visual observation and record review, the facility failed to assure that the weekly inspection and a monthly testing program on the emergency generator was conducted and documented. 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 13 of 13 residents.
11 of 12 months were deficient.

Findings:

During the record review on 2/18/2019, between the hours of 8:30a-3:00p record review revealed weekly and monthly emergency generator testing documentation was not provided.

Interview with Administrator revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator.