HospitalInspections.org

Based on record review and interview, the facility failed to develop and maintain an Emergency Preparedness (EP) plan that must be reviewed and updated at least every two years. This deficient practice could affect 115 out of 115 occupants in the event of a facility wide emergency or disaster.

Findings Include:
On July 10, 2024, at approximately 1:00 PM record review revealed the facility had several EP books throughout the facility with different review dates in the books. The dates ranged from 2008 at the fourth floor nursing station and a book dated May 2023 which was produced to the surveyor at the time of record review.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on record review and interview the facility failed to conduct a facility-based and community based risk assessment in their Emergency Preparedness Plan resulting in the potential for failure to identify hazards associated with the facility. This deficient practice could affect 115 out of 115 occupants in the event of a facility wide emergency or disaster.

Findings include:
On July 10, 2024, at approximately 1:00 PM, record review revealed the facility failed to document in their "Emergency Preparedness Plan" a facility-based and community-based risk assessment utilizing an all-hazards approach. No all-hazards risk assessment was available at the time of survey and no documents were received by the time of exit.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on record review and interview, the facility failed to provide policies and procedures for a means to shelter in place for patients, staff and volunteers who remain in the facility. This deficient practice could affect 115 out of 115 occupants in the event of a facility wide emergency or disaster.

Findings Include:
On July 10, 2024 at approximately 1:00 PM, record review revealed the facility failed to provide a Shelter in Place policy in the Emergency Preparedness Plan. No plan was available at the time of survey and no document received by the time of exit.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on record review and interview, the facility failed to provide initial training in emergency preparedness policies and procedures to all new and exiting staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. Provide Emergency Preparedness training at least annually, maintain documentation of the training and demonstrate staff knowledge of emergency procedures. This deficient practice could affect 115 out of 115 occupants in the event of a facility wide emergency or disaster.

Findings Include:
On July 10, 2024, at approximately 1:00 PM, record review revealed the facility failed to provide a policy and records of the required initial emergency preparedness training courses and annual updates. No employee training program or records of employee training was available at the time of survey and no documents received by the time of exit.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on record review and interview, the facility failed to conduct exercises to test the emergency plan at least every two years, including unannounced staff drills using the emergency procedures. This deficient practice could affect 115 out of 115 occupants in the event of a facility wide emergency or disaster.

Findings Include:
On July 10, 2024, at approximately 1:00 PM. record review revealed there was no documentation provided for the required annual tabletop and community-based full-scale exercise nor any documentation of an actual event that would qualify as a test of the emergency plan within the last two year. No documentation or after-action reports for a table-top or full scale facility wide drill were available at the time of survey and no documents received by the time of exit.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on observation and interview, the facility failed to ensure building construction types and numbers of stories met the requirements of Table 19.1.6.1, unless permitted by 19.1.6.2 through 19.1.6.7. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:

On 07/09/2024 at approximately 12:42 PM, observation revealed the fire rated retardant coating on the steel ceiling has fallen, creating a 2 foot by 3 foot section unprotected from the required structural rating, located in the IT Room G10 off of stairwell 7.

This finding was confirmed by interview with Maintenance Supervisor at the time of observation.

Based on observation and interview, the facility failed to ensure aisles, passageways, corridors, exit discharges, exit locations and accesses are in accordance with Chapter 7, and continuously maintained free of all obstructions to full use in case of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect 30 occupants in the event of a fire emergency.

Findings Include:

On 07/09/2024 at approximately 11:38 AM, observation revealed the emergency exit at the bottom of stairwell #3, took three atempts, pushing excessively hard to open the door exceeding the allowable pounds of pressure to open the door.

This finding was confirmed by interview with Maintenance Supervisor at the time of observation.


36613

On 07/09/2024 at approximately 11:48 AM, observation revealed 5 chairs in a row in the emergency egress corridor adjacent to room 520, on 5th floor northeast. This will restrict the emergency egress corridor and delay or inhibit emergency egress.

This finding was confirmed by interview with Maintenance Supervisor at the time of observation.

Based on observation and interview, the facility failed to ensure doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress side unless meeting the special locking arrangements for delayed egress locking in accordance with 19.2.2.2.4. This deficient practice could trap all occupants inside the facility the event of an emergency evacuation.

Findings Include:

A) On July 9, 2024 at approximately 11:35 AM, observation revealed the exit door to stairwell number #3 was equipped with delayed egress hardware. When the activation bar for the delayed egress was pushed, no activation process occurred, in violation of 2012 NFPA 101, 7.2.1.6.1.1(3).
B) On July 9, 2024 at approximately 12:40 PM, observation revealed the exit door located on 3rd floor southeast was equipped with delayed egress hardware. When the activation bar for the delayed egress was pushed, no activation process occurs in violation of 2012 NFPA 101, 7.2.1.6.1.1(3).
C) On July 9, 2024 at approximately 1:40 PM, observation revealed the 1st floor south cross corridor exit doors adjacent from endoscopy 1 were locked and cannot be released except by use of a badge. During interview at this time, Maintenance staff stated; "only badges on the old system can unlock these doors." The area does not meet clinical needs door locking; the doors are general egress and in violation of 2012 NFPA 101, 19.2.2.2.4.

D) On July 9, 2024 at approximately 12:50 PM, observation revealed the 3rd floor cross corridor double doors by exam room 6 and patient room 363 were locked and cannot be released except by use of a badge. During interview at this time, Maintenance staff stated; "only badges on the old system can unlock these doors." The area does not meet clinical needs door locking, the doors are general egress and in violation of 2012 NFPA 101, 19.2.2.2.4.

These findings were confirmed with maintenance staff through interview at the times of observation.

Based on observation and interview, the facility failed to ensure the means of egress is illuminated in accordance with 7.8, as required by 19.2.8. This deficient practice could affect 5 occupants in the event of a power outage.

Findings Include:

On 07/09/2024 at approximately 11:14 AM, observation revealed the emergency egress lights located in the upstairs powerhouse generator room did not illuminate when tested.

This finding was confirmed by interview with the Powerhouse Boiler Tech at the time of observation.

Based on record review and interview, the facility failed to ensure automatic emergency lighting of 1-1/2 hour duration is provided in accordance with 7.9, as required by 19.2.9.1. This deficient practice could affect 115 out of 115 occupants in the event of a fire emergency or power outage.

Findings Include:
On July 9, 2024 at approximately 1:15 PM, record review revealed the facility failed to provide documentation on the 30 second and 90-minute test, inspection and maintenance of the battery powered emergency lights located throughout the facility. No documents were available at the time of survey.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on observation and interview, the facility failed to ensure hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. This deficient practice could affect 20 occupants in the event of a fire. This may allow heat, smoke and fire to escape the storage space and spread into the emergency egress corridor.

Findings Include:
On July 9, 2024 at approximately 11:25 AM, observation revealed patient room 701 had been converted into a storage room and contained pallets of mattresses. The space was observed to be protected with automatic fire suppression, however, the door to the space is not automatic closing as required by 2012 NFPA 101, 19.3.2.1.3.

These findings were confirmed through interview with the maintenance director at the time of observation.

Based on observation, interview, and record review, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96, unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.4.4, as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3 and TIA 12-2. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:
1. On 07/09/2024, at approximately 1:20 PM, record review revealed the facility failed to provide documentation of a kitchen hood automatic wet chemical extinguishing system inspection at a minimum of 6 (six) month intervals. No kitchen hood wet chemical extinguishing reports were available at the time of survey.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

2. On 07/09/2024 at approximately 12:21 PM, observation revealed the kitchen hood exhaust system was not operating at the time of survey while the facility staff was cooking.

3. On 07/09/2024 at approximately 12:26 PM, observation revealed the deep fryer next to the open flame griddle does not have an 8" splash shield protecting against grease splashing on the open flame griddle.

4. On 07/09/2024 at approximately 12:27 PM, observation revealed the deep fryer was not positioned under the kitchen hood suppression for proper coverage in an event of a fire.

5. On 07/09/2024 at approximately 12:28 PM, observation revealed the facility failed to maintain the kitchen hood located in the main kitchen free of grease build-up on the baffles. Heavy grease was observed on the hood baffles throughout the entire hood.

These findings were confirmed by interview with Maintenance Supervisor at the time of observations.

Based on observation and interview, the facility failed to ensure a fire alarm system is installed in accordance with NFPA 70 and NFPA 72, as required by 19.3.4.1, 9.6 and 9.6.1.8. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:

07/09/2024 at approximately 1:36 PM, observation revealed the fire alarm circuit breaker lock was missing in the circuit breaker panel located in the basement electric room.

This finding was confirmed by interview with Maintenance Supervisor at the time of observation.

Based on observation, interview, and record review, the facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72, and records are readily available as required by 19.6.1.3, 9.6.1.5, NFPA 70 and NFPA 72. This deficient practice could affect 115 out of 115 occupants in the event of a fire emergency.

Findings Include:
1. On July 9, 2024 at approximately 11:30 AM, record review revealed the facility failed to record the required 2 year sensitivity testing on the fire alarms smoke detectors. No sensitivity test was available at the time of survey.

2. On July 9, 2024 at approximately 11:30 AM, record review revealed the facility failed to provide documentation on the annual inspection, testing and maintenance on the facility's automatic fire alarm system. The annual inspection report available for review was dated May 17, 2023.

3. On July 9, 2024, at approximately 11:30 AM, record review of the annual fire alarm inspection report dated May 17, 2023, found the facility failed to correct or repair the fire alarm deficiencies noted during the inspection. The Maintenance Supervisor stated the work was almost done at the time of survey.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

4. On 07/09/2024 at approximately 11:03 AM, observation revealed the display was not working for the fire panel annunciator located in the powerhouse.

5. On 07/09/2024 at approximately 11:41 AM, observation revealed duct detector trouble mode for the main fire alarm panel located in the old security office.

These findings were confirmed by interview with Maintenance Supervisor at the time of observation.

Based on observation, interview, and record review, the facility failed to ensure when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction (AHJ) has been notified, and all unprotected areas of the building have been evacuated or an approved Fire Watch is provided until the system is restored as required by 9.6.1.6. This deficient practice could affect 115 out of 115 occupants in the event of a fire emergency.

Findings Include:

A) On July 9, 2024 at approximately 2:00 PM, record review and interview with the Facility Manager revealed the facility was placed in fire watch since approximately February 19, 2024. The facility failed to notify the Authority Having Jurisdiction (State of Michigan) of the facility being in fire watch due to multiple impairments of the required fire alarm system. By the time of survey exit, the facility failed to provide a date or written plan as to when the fire alarm system would be restored.


36613

B) On July 9, 2024 at approximately 1:05 PM, observation revealed the fire pull station next to stairwell 1 on level 3 southeast is broken and hanging from the wall and separated into 2 pieces. This will prohibit activation of the fire alarm system.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on observation and interview, the facility failed to ensure hospitals where required by construction type are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, as required by 19.3.5.1 through 19.3.5.5, 19.4.2, 19.3.5.10, 9.7 and 9.7.1.1(1). This deficient practice could affect 30 occupants in the event of a fire emergency.

Findings Include:

A) On 07/09/2024 at approximately 1:25 PM, observation revealed in the old Physical Therapy room over 20 pallets full of combustible material stacked approximately 5 feet high without any fire suppression sprinkler coverage.


36613

B) On 07/09/2024 at approximately 1:00 PM, observation revealed the 3rd floor south resident call room is missing 3 ceiling tiles due to a water leak. This will allow heat to bypass the sprinkler heads and enter the adjacent void space above the ceiling and delay activation of the automatic wet fire suppression system.

C) On 07/09/2024 at approximately 1:10 PM, observation revealed missing ceiling tiles in the 3 south nurse station coat room. This will allow heat to bypass the sprinkler heads and enter the adjacent void space above the ceiling and delay activation of the automatic wet fire suppression system.

D) On 07/09/24 at approximately 1:20 PM, observation revealed all ceiling tiles in the main Lab room 237 are missing due to a sewage line break. This will allow heat to bypass the sprinkler heads and enter the adjacent void space above the ceiling and delay activation of the automatic wet fire suppression system.

E) On 07/09/24 at approximately 1:35 PM, observation revealed missing ceiling tiles in the first floor south pain clinic room 132 from a water leak. This will allow heat to bypass the sprinkler heads and enter the adjacent void space above the ceiling and delay activation of the automatic wet fire suppression system.

These findings were confirmed by interview with Maintenance Supervisor at the time of observation.

Based on observation, interview, and record review, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, and records are readily available as required by 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect 115 out of 115 occupants in the event of a fire emergency.

Findings Include:
A) On July 9, 2024, at approximately 11:40 AM, record review revealed the facility failed provide documentation of the automatic sprinkler systems required quarterly maintenance and water flow tests. The last quarterly water flow and maintenance report available at the time of survey was dated February 6, 2024.

B) On July 9, 2024, at approximately 11:40 AM, record review revealed the facility failed provide documentation of the repairs and corrections of the deficiencies noted on the NFPA 25, quarterly inspection report dated February 6, 2024. The deviancies are noted on page #15 of the report.

C) On July 9, 2024, at approximately 11:40 AM, record review revealed the facility failed provide documentation of required annual inspection and maintenance of the sprinkler system's fire pump. No annual inspection form was available at the time of survey.

D) On July 9, 2024, at approximately 11:40 AM, record review revealed the facility failed provide documentation of required pump performance flow test and maintenance of the sprinkler system's fire pump. No annual inspection form was available at the time of survey.

E) On July 9, 2024, at approximately 11:40 AM, record review revealed the facility failed provide documentation of required churn test and maintenance of the sprinkler system's fire pump. Monthly churn tests were not recorded for the months of February, April and June of 2024.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.


36613

F) On July 9, 2024 at approximately 1:50 PM, observation revealed the sprinkler heads outside of patient registration on the first floor are loaded and dust covered in violation of 2011 NFPA 25, 5.2.1.1.1. This may lead to the sprinkler heads not functioning as designed when needed during a fire.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on record review and interview, the facility failed to ensure portable fire extinguishers are selected, installed, inspected and maintained in accordance with NFPA 10, as required by 19.3.5.12. This deficient practice could affect 20 out of 115 occupants in the event of a fire emergency.

Findings Include:

On July 10, 2024 at approximately 11:35 AM. record review revealed the facility failed to record the required monthly inspection on the portable fire extinguisher located in the basement SSR processing room. Twelve months of consecutive inspections were not documented on the portable fire extinguisher's maintenance tag.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.


36613

On July 9, 2024 at approximately 1:00 PM record review revealed the facility fire extinguisher number 4-004 located on nurse station 4 south is not being inspected at 30 day intervals as required by 2010 NFPA 10, 7.2.1.2. The monthly inspection tag on the fire extinguisher does not have any dates recorded.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on observation and interview, the facility failed to ensure smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5, as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:

On 07/09/2024 at approximately 12:42 PM, observation revealed a 4 inch by 4 inch hole was cut in the steel ceiling creating an unsealed penetration for a cable to run through the ceiling, located in the IT Room G10 off of stairwell 7.

This finding was confirmed by interview with Maintenance Supervisor at the time of observation.

Based on observation and interview, the facility failed to ensure doors in smoke barriers are 1-3/4 inch solid bonded wood-core doors or construction that resists fire for 20 minutes, are self-closing or automatic-closing and provide a minimum width of 32 inches as required by 19.3.7.6, 18.3.7.8 and 19.3.7.9. This deficient practice could affect 70 occupants in the event of a fire.

Findings Include:

A) On July 9, 2024 at approximately 11:15 AM, observation revealed the rated double fire doors next to exam room 744 have had the fire rated glass windows removed leaving openings in the doors. The doors will not resist the passage of smoke and allow heat, smoke and fire to pass into the adjacent building compartment.

B) On July 9, 2024 at approximately 12:40 PM, observation revealed the rated double fire doors on 3rd floor south next to exam room 343, were being held open with wedges shoved under the doors. The doors will not automatically close to resist the passage of smoke and allow heat, smoke and fire to pass into the adjacent building compartment.

C) On July 9, 2024 at approximately 1:00 PM, observation revealed the 3rd floor southwest wing double rated fire doors next to nursery room 374 have had the rated glass removed leaving openings in the doors. The doors will not resist the passage of smoke and allow heat, smoke and fire to pass into the adjacent building compartment.

D) On July 9, 2024 at approximately 1:00 PM, observation revealed the 3rd floor south double rated fire doors next to waiting room 387 have had the rated glass removed leaving openings in the doors. The doors will not resist the passage of smoke and allow heat, smoke and fire to pass into the adjacent building compartment.

E) On July 9, 2024 at approximately 1:10 PM, observation revealed the 2 south double doors adjacent from the large mechanical room do not latch and burst open when the mechanical room door is opened. The massive amount of air balance forces the rated fire doors open. This will allow heat, smoke and fire to be forced through the rated doors and into the adjacent compartment.

F) On July 9, 2024 at approximately 2:40 PM, observation revealed the smoke barrier doors leading into the first floor urgent care suite are not hooked up to the automatic closer devices. This will allow smoke, heat and fire to enter the adjacent building compartment.

These findings were confirmed through interview with maintenance staff at the time of observation.

Based on record review and interview, the facility failed to ensure heating, ventilation and air conditioning is in compliance with 9.2, and installed in accordance with the manufacturer's specifications as required by 19.5.2.1 and 9.2. This deficient practice could potentially affect all occupants of the facility in the event of a fire where smoke and heat are allowed to pass protection barriers.

Findings Include:
On July 9, 2024 at approximately 1:15 PM, record review revealed the facility failed to provide document requirements for inspection of dampers. No damper inspection reports were available at the time of survey.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on record review and interview, the facility failed to ensure elevators comply with the provisions of 9.4, are inspected and tested as specified in ASME A17.1 or ASME/ANSI A17.3 including firefighter's service as required by 19.5.3, 9.4.2 and 9.4.3. This deficient practice could affect 115 out of 115 occupants in the event of a facility emergency.

Findings Include:
A) On July 9, 2024 at approximately 1:15 PM, record review revealed the facility failed to provide documentation of the elevators required annul inspection and maintenance. No documents were available at the time of survey.

B) On July 9, 2024 at approximately 1:15 PM, record review revealed the facility failed to provide documentation of the elevators required monthly firefighter service override. No documents were available at the time of survey.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on record review and interview, the facility failed to ensure there is a written plan for the protection of all residents and for their evacuation in the event of an emergency, employees are periodically instructed in their duties under the plan, the plan is readily available, addresses the basic response required by staff and provides all components as required by 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2 and 19.7.2.3. This deficient practice could affect 115 out of 115 occupants in the event of a fire emergency.

Findings Include:
On July 9, 2024 at approximately 1:30 PM, record review revealed the facility failed to provide a floor plan identifying the location of the fire/smoke barriers in the fire evacuation plan and the floor plan was not available to the fire safety inspector at the fourth floor nursing station. Staff cannot evacuate residents to an area of refuge (adjacent smoke compartment) without knowledge of their locations.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on record review and interview, the facility failed to ensure fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions, are held at unexpected times under varying circumstances, conducted at least quarterly on each shift and responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership as required by 19.7.1.4 through 19.7.1.7. This deficient practice could affect 115 out of 115 occupants in the event of a fire emergency.

Findings Include:
On July 9, 2024, at approximately 11:50 AM, record review revealed the facility failed to provide documentation the alarm signals generated by the required fire drills were transmitted and received by the fire alarm monitoring company. Documents or activity reports to ensure the transmission of alarm during fire drills were not available for all the fire drills conducted over the last calendar year.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on observation and interview, the facility failed to ensure 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 as required by 19.7.8. This deficient practice could affect 25 occupants in the event of a fire.

Findings Include:

On July 9, 2024 at approximately 12:40 PM, observation revealed 2 portable space heaters in use in the level 4 northeast social workers office. The ceramic element space heaters could not be verified to have heating elements less than 212 degrees as required by NFPA 101, 19.7.8. The facility failed to provide a policy for the use of portable space heaters and this may lead to a space heater related emergency or fire event.

These findings were confirmed through interview with maintenance staff at the time of observation.

Based on record review and interview, the facility failed to ensure generators or other alternative power sources and associated equipment is capable of supplying service within 10 seconds, is maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4 and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could affect 115 out of 115 occupants in the event of a fire emergency or power outage.

Findings Include:
A) On July 9, 2024, at approximately 12:30 PM, record review revealed the facility failed to document the required annual inspection and load bank testing on the emergency generators. No annual inspection documents were available at the time of survey for both generator #1 and #2.

B) On July 9, 2024, at approximately 12:30 PM, record review revealed the facility failed to document the required annual fuel test for the emergency generators.

C) On July 9, 2024, at approximately 12:30 PM, record review revealed the facility failed to document battery tests on the required monthly inspection of the facility's two generators. The monthly tests of the battery must include the specific gravity of the battery fluids or cold crank amperage if the battery is of a maintenance free design to ensure the cells are in operational condition.

D) On July 9, 2024, at approximately 12:30 PM, record review revealed the facility failed to document the required weekly inspection on the facility's two emergency generators. No weekly inspection documents were available since January 1, 2024, at the time of survey.

The Facility Manager and Administrator confirmed these findings during the exit interview and at the time of record review.

Based on observation and interview, the facility failed to ensure power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99, 400-8 of NFPA 70 and TIA 12-5, and extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect 20 occupants in the event of a fire emergency.

Findings Include:

A) On 07/09/2024 at approximately 11:47 AM, observation revealed two power strip multi-plug extension cords were plugged into another multi-plug extension cord located in the communication room.

B) On 07/09/2024 at approximately 12:36 PM, observation revealed a toaster plugged into a power strip multi-plug extension cord located in the dining room.

These findings were confirmed by interview with Maintenance Supervisor at the time of observation.


36613

C) On 07/09/2024 at approximately 1:05 PM, observation revealed two electrical surge protector power strips connected together in the 3rd floor southeast room 234. With plugs leading to all outlets in the powerstrips. This may overload the electrical circuit creating electrical resistance leading to sufficient heat to start an electrical fire.

These findings were confirmed by interview with Maintenance Supervisor at the time of observation.