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Based on observation, review of documentation and interview, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 9.7.5
2011 NFPA 25, 5.3.1.1.1.3, and 5.3.1.1.1.6

This deficiency could affect 30 occupants.

Findings include:

On 11/04/2019, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed the following:
1. The facility failed to provide documentation that the 1996 fast-response sprinklers located in the Emergancy Waiting Area and throughout building had been replaced or a representative sample tested within 20 years of installation.
2. The 1997 dry sprinkler heads in the walk in cooler and freezer had been replaced or a representative sample tested within 10 years of installation

A member of the maintenance staff and was present, when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

This deficiency could affect 20 residents

Findings include:

On 11/04/2019, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed several approximately 3/4" unsealed penetrations of white wires in the smoke barrier above the ceiling near Labor and Delivery. It appeared that the fire had been pulled from the penetration.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to conduct fire drills per the requirements of:

2012 NFPA 101, 19.7.1.6, and 4.7.2

This deficiency could affect all residents.

Findings include:

On 11/04/2019, during the review of documentation from 9:00 am to 3:30pm the facility provided the following documentation:
First Shift
10/21/2019 - 10:40 pm
07/18/2019 - 1:30 pm
04/17/2019 - 8:40 am
01/09/2019 - 8:30 am

Second Shift
08/14/2019 - 4:20 pm
05/19/2019 - 3:40 pm
02/12/2019 - 3:10 pm
11/06/2018 - 5:15 pm

Third Shift
09/16/2019 - 4:20 pm
06/24/2019 - 6:00 am
03/18/2019 - 4:20 pm
12/14/2018 - 4:30 pm

All of third shift drills for the entire year were within 1 hour and 40 minutes for an eight hour shift.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to ensure continuing education on the handling and risks associated with oxygen cylinders and other medical gases stored in cylinders per the requirements of:

2012 NFPA 99, 11.5.2.1

This deficiency could affect approximately xx occupants.

On 11/04/2019, during a tour of the facility from 9:45 am to 4:00 pm, the facility failed to provide documentation on the following for portable cylinders (the facility did have this documentation for the piped gases):
1. The qualifications and training of the facility's training personnel on handling oxygen cylinders/medical gases and their cylinders.
2. Continuing education to include periodic review of safety guidelines and usage requirements for personnel that handle oxygen cylinders/ medical gases and their cylinders, including new hires.

A member of the maintenance staff was present when this deficiency was identified.