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Based on observation and interview, the facility failed to protect door opening in stairwell enclosure in accordance with NFPA 101 19.3.1, 8.6.5, 8.3.4.2, 8.3.3.1. This deficiency had a potential to affect undetermined number of staff in the facility.

Findings include

On 10/06/21 at 11:32 am, observation revealed that the Stair Exit Door 4-11, an opening protective in the fire-rated stairway enclosure in Unit 44D Level 2 of Building #4, closed but did not latch. This deficiency was confirmed by Staff M2 at the time of discovery, and by Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2 pm.

Based on observation and interview, the facility failed to construct one exit discharge in accordance with NFPA 101 (2012 edition) 19.2.1, 7.1.6.2. This deficiency had the potential to affect patients in two of four patient care areas, and undetermined number of staff and visitors.

Findings include

On 10/06/21 at 10:30 am, observation revealed that the exit discharge from Stairwell Exit 56 had one 8 inch change in elevation-step down. There was no ramp provided to overcome the change in elevation of more than 1/4 inch as required.

This deficiency was confirmed by Staff M2 at the time of discovery, and by Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on observation and interview, the facility failed to provide emergency lighting in accordance with NFPA 101 19.2.9.1, 7.9.1. This deficiency had a potential to affect an undetermined number of staff in the facility.

Findings include

Observation on 10/06/21 at 4:03 pm, revealed that the Penthouse above Unit 44F of Building #4 did not have emergency lighting in access aisle from the remote area of the penthouse to the exit access door. This deficiency was confirmed by an interview with Staff M2 and Staff M3 at the time of discovery, and with Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on observation and interview, the facility failed to protect hazardous areas in accordance with NFPA 101 19.3.2.1, 8.4.3.5. This deficiency had a potential to affect an undetermined number of staff in 2 of 75 smoke compartments in the facility.

Findings include

Observation on 10/06/21 between 10:15 am and 11:15 am, and an interview with Staff M2 on 10/07/21 at 8:45 am, revealed that rooms in the following units that were previously used as patient rooms, or conference, or dining/activity rooms were deemed hazardous due to furniture and other combustible storage, but doors of these rooms were not self-closing due to lack of door closers.

1. Corridor doors of Unit 43F Rooms 1, 2, 6, 7, 25, 26, 29, 30, 31, 33, 34, 35, 36, 37, 38 did not have door closers.

2. Corridor doors of Unit 43E Room 24 of Building #4, previously used as a conference room, Room 25 previously used as a library, Patient Rooms 1, 2, 6 and 7, 26, 29, 30, 31, 33, 34, 35, 36, 37, 38 and 40.

3. Corridor double doors of Unit 43A Room 13 of Building #4, previously used as a conference room did not have door closers.

This deficiency was confirmed by Staff M2 at the time of discovery, and by Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on observation, record review and interview, the facility failed to properly maintain the fire alarm system: semi-annual visual inspection in accordance with NFPA 101 (2012 edition) 19.3.4.1, 9.6.1.3, NFPA 72 (2010), 14.3.1(3)(d), 14.3.1(9); and semi-annual testing in accordance with NFPA 72 14.4.2.2, 14.4.5 Table 14.4.5(6)(d)(3). This deficient practice affected all patients, and an undetermined number of staff and visitors in the facility.

Findings include:

1. On 10/05/21 between 1:30 pm and 3:00 pm, review of fire alarm maintenance and inspection records revealed that the semi-annual visual inspection of sealed lead-acid fire alarm batteries, and duct detectors and smoke detectors was not performed.

2. On 10/05/21 between 1:30 pm and 3:00 pm, review of fire alarm maintenance and inspection records revealed that semiannual load voltage test of sealed lead-acid fire alarm batteries was not performed.

3. On 10/06/21 at 10:15 am, observation revealed that one ceiling-mounted corridor smoke detector adjacent to cross-corridor smoke doors on 3rd Floor of Building #4 was covered with a gray color duct tape preventing entry of smoke into sensing chamber of the detector. The smoke doors were located near the point of entry into Unit 43C.

Items 1 and 2 of the above deficiency were confirmed by interview with Staff M1 and M3 at the time of discovery. Item 3 confirmed by interview with Staff M2 at the time of discovery, and with Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at the exit interview on 10/07/21 at 2:00 pm.

Based on observation and interview, the facility failed to maintain the corridor wall smoke tight condition in one location due to an unsealed penetration in accordance with NFPA 101, 2012 ed., Chp. 19.3.6.2.3. This deficiency had a potential to affect an undetermined number of staff in the facility.

Findings include

Observation on 10/07/21 at 9:37 am revealed that the a 1-1/2 inch orange color cable container penetration of corridor wall was not sealed to prevent smoke transfer. The penetration was located in the Computer Room in Level 2 of Building #4.

The above deficiency was confirmed by an interview with Staff M1 and Staff M2 at the time of discovery, and with Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on observation and interview, the facility failed to maintain corridor doors of two rooms in accordance with NFPA 101, 2012 ed., chp. 19.3.6.3.5. This deficiency had a potential to affect undetermined number of staff in the facility in 2 of 75 smoke compartments in the facility.

Findings include

Observation on 10/06/21 between 10:15 am and 11:15 am revealed that (i) the corridor door of Unit 43F Room 2 of Building #4, previously a patient room, hit the top door frame and did not close; and (ii) the Unit 43E Corridor Door of Room 12, previously used as a dining room, was held open with a plastic wrap fastened to the corridor handrail, which caused an impediment to closing the door in the event of a fire emergency.

This deficiency was confirmed by Staff M2 at the time of discovery, and by Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on observation and interview, the facility failed to maintain the fire resistance rating of the smoke barrier wall in accordance with NFPA 101, 2012 ed, chp. 19.3.7.3, 8.5.6.5. This deficiency had a potential to affect an undetermined number of staff and visitors in the facility.

Findings include

Observation on 10/06/21 at 10:33 am revealed that one smoke barrier penetration, by a 2 inch sleeve containing data wires, was not caulked smoke-tight to form a barrier to smoke passage. The penetration was located above smoke doors adjacent to Suite 1096 in Building #3 Level 1.

This deficiency was confirmed by interview with Staff M1 at the time of discovery, and with Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on observation and interview, the facility failed to maintain smoke barrier doors in three locations in accordance with NFPA 101, 2012 ed., chp. 19.3.7.8, 8.5.4.1. This deficiency had a potential to affect all patients in Unit 53A, and an undetermined number of staff and visitors in the facility.

Findings include

1. Observation on 10/06/21 between 11:16 am and 11:27 am revealed that the cross-corridor smoke doors 3322-32 adjacent to Room 35 in Unit 44A of Building #4, did not close when manually released. The cross-corridor smoke doors adjacent to Rooms 33 and 35 in Unit 44B of Building #4 did not close; the doors hit the top frame and left a gap of 1 inch at the meeting edge of doors.

2. Observation on 10/06/21 at 3:50 pm revealed that a pair of smoke doors in an opening of the fire barrier between the Maintenance Storage and Repair Shop in Building #4 Level 2 were electro-magnetically held-open but did not fully close when released.

First item of the above deficiency was confirmed by interview with Staff M2 at the time of discovery, and 2nd item of the deficiency with Staff M2 and Staff M3 at the time of discovery, and with Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on observation and interview, the facility did not maintain the electrical raceway in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.2 and NFPA 70 - 2011 edition sections 314.28(C) and Article 110.22. This deficiency had the potential to affect an undetermined number of staff and visitors.

Findings include:

On 10/06/2021 at 10:34 am, observation revealed in the Classroom Room #1097 in Building 3 Level 1 that a 8 inch x 8 inch metal electrical junction box mounted in the wall did not have a cover.

This deficiency was confirmed by interview with Staff M1, Staff M2 and Staff M3 at the time of discovery, and with Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on record review and interview, the facility did not perform testing of the emergency generator batteries in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1 and 9.1.3; and NFPA 110 (2010 edition) Sections 8.3.7, 8.4.1, 8.4.2, & 8.4.6. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors in the facility.

Findings include:

On 10/05/2021 at 2:45 pm, review of the monthly generator documentation revealed that neither specific gravity testing nor conductance testing of the generator batteries was recorded for 12 of last 12 months.

This deficient practice was confirmed by interview with Staff M1, Staff M2 and M3 at the time of discovery, and with Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.

Based on observations and staff interview, the facility failed to properly maintain electrical devices in accordance with NFPA 101 (2012 edition), Sections 19.5.1.1 and 9.1.2, and NFPA 70 (2011 edition) Sections 400.8, 590.2(B). This deficiency could affect an undetermined number of staff in the facility.

Findings include:

1. On 10/07/2021 at 9:25 am, observation in the back room of the Pharmacy in Building 4 level 2 revealed a flexible cord multi-outlet strip device powering a coffeemaker, microwave oven, toaster and a Keurig coffeemaker.

2. On 10/07/2021 at 9:28 am, observation in the Pharmacy Office room # 2201-4 in Building 4 level 2 revealed a flexible cord multi-outlet strip device powering a coffeemaker.

The above deficiency was confirmed by a concurrent interview with Staff M1, Staff M2 and Staff M3 at the time of discovery, and with Staff A, Staff C, Staff Q, Staff M1 and Staff M2 at exit interview on 10/07/21 at 2:00 pm.