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Based on observation it was determined the facility failed to maintain one illuminated exit sign in the Juniper Unit main stairwell. Failing to install and maintain the illuminated exit sign could cause harm to the staff and residents in time of a fire or emergency.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.2.10.1, Means of egress shall have signs in accordance with Section 7.10 unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. Chapter 7, Section 7.10.1.2.1, "Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access." Section 7.10.1.5.1, "Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants."

Findings include:

1. Observations while on tour September 17, 2020 revealed that the exit light at the bottom of the exit stairwell for the Juniper Unit was not illuminated. The first floor building exit for the Palo Verde Unit was blocked from the inside and was not an exit from the building. The door did not have the required sign that reads NO EXIT.


Employee's # 2 and 25 confirmed during the exit conference on September 17, 2020 that the exit light at the bottom of the exit stairwell for the Juniper Unit was not illuminated and the first floor building exit for the Palo Verde Unit was blocked from the inside and was not an exit from the building. The door did not have the required sign that reads NO EXIT.

Based on observation the facility failed to maintain the fire barrier by not maintaining the self-closing device on the fire door. Failing to maintain fire barriers could allow a fire to spread more rapidly through the two hour fire barrier and give residents less time to evacuate the building.

NFPA 101 Life Safety Code, 2012, Chapter 21 Existing, Section 21.3.2 1 Doors to hazardous areas shall be self-closing or automatic closing in accordance with 21.2.2.4. Section 21.2.2.4 Any door required to be self-closing shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. Section 7.2.1.8.2
The required manual fire alarm system and the systems required by 7.2.1.8.2. shall be arranged to initiate the closing action of all such doors throughout the entire facility.

"Protection from Hazards" Chapter 39 Section 39.2.2.2 Doors Section 39.2.2.2.1 Doors complying with 7.2.1 shall be permitted. Chapter 39, Section 39.3.2.1, General "Hazardous areas including, but not limited to, areas used for general storage... shall be protected in accordance with Section 8.7." Chapter 8, Section 8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3/4 hour fire protecting rating and shall be self or automatic closing in accordance with 7.2.1.8. Section 7.2.1.8.1 A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self or automatic closing in accordance with 7.2.1.8.2.

Findings include:

Observations while on tour September 17, 2020 revealed the door at the bottom of the long hallway failed to close and latch after three (3) failed attempts.

Employee # 2 and 9 confirmed on September 17, 2020 the door at the bottom of the long hallway failed to close and latch after three (3) failed attempts.

Based on record review and interview with staff, it was determined the facility did not have a kitchen hood system in accordance with NFPA 96. Failing to install a kitchen hood system it increases the build-up of grease and provide fuel for a fire. A fire in the kitchen has potential to risk the lives of the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... "Chapter 4, Section 4.1.1 "Cooking equipment used in processes producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard." Section 4.1.2 "All such equipment and its performance shall be maintained in accordance with the requirements of this standard during all periods of operation of the cooking equipment." Chapter 10, Section 10.1.2 "Cooking equipment that produces grease-laden vapors and that might be a source of ignition of grease in the hood, grease removal device, or duct shall be protected by fire extinguishing equipment."


Observations while on tour September 17, 2020 revealed the kitchen facility was utilizing a grease producing grill. The facility was not equipped with an exhaust hood. The grill was not in use at time but had been used recently as evidenced by grease on the wall and ceiling above the grill. The grill has a plug wire that was pulled away from the grill exposing the internal wires.

Employees # 2 and 9 confirmed the staff utilizes the grill daily to feed the patients and staff.

Employee # 1 had staff remove and dispose of the grill from the kitched area.

Employees # 1, 2 and 9 confirmed during the exit conference on September 17, 2020 the grease producing grill in the kitched area was being used daily for cooking meals for patients and staff and The grill has a plug wire wire that was pulled away from the grill exposing the internal wires.

Based on observation it was determined the facility failed to protect the entire facility with an automatic sprinkler system. This would result in the sprinkler system not being able to extinguish the fire and could result in injury or death to the building occupants.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 8 Obstructions to Sprinkler Discharge Pattern Development. Section 8.6.5.2.1.1 Continuous or noncontiguous obstructions less than or equal to 18 in. below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.6.5.2.

Findings include:

Observations while on tour September 17, 2020 revealed the Medical Directors office was not protected by the sprinkler system. The sprinkler head was not installed properly during a recent building modification the sprinkler head was installed directly above the drop ceiling tile. The ceiling tile would prevent the sprinkler from actuating in the event of a fire.

Employees # 1, 2 and 9 confirmed during the exit conference on September 17, 2020 the Medical Directors office was not protected by the sprinkler system. The sprinkler head was not installed properly during a recent building modification the sprinkler head was installed directly above the drop ceiling tile. The ceiling tile would prevent the sprinkler from actuating in a fire

Based on observation it was determined that the facility failed to keep the sprinkler heads clean. Failing to maintain the sprinkler heads which are part of the entire sprinkler assembly could cause harm to the residents by allowing a fire to spread before the temperature is reached to set off the sprinkler head.

NFPA 101 Life Safety Code, 2012 edition, Chapter 19, Section 19.3.5.3
Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage." Section 5.2.1.1.2 Any sprinkler that shows the signs of any of the following shall be replaced. 1. leakage
2. Corrosion 3. Physical damage 4. Loss of fluid in the glass bulb heat responsive element
5. * Loading See A.5.2.1.1.2 (5) In lieu of replacing sprinklers that are loaded with a coating of dust , it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler. 6. Painting unless painted by the manufacturer. Section 5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage, is painted other than by the manufacturer, corroded, damaged, or loaded, is in the improper orientation. Annex E Examples of Classification of needed repairs Sprinklers and Escutcheon plates that are missing, painted or rusted.

Findings Include:

Observations while on tour September 17 2020 revealed that four (4) out of ten (10) heads were dirty in the kitchen area.

During the exit conference on September 17 2020 employee# 1 and 2 confirmed that four (4) out of ten (10) heads were dirty in the kitchen area.

. Based on record review and interview it was determined fire drills were conducted but not documented correctly for the past three (3) years. The could have resulted in the staff not being properly trained and unable to evacuate the patients in a timely fashion which could result in injury or death.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.2.2 written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Emergency phone call to the fire department
4. Response to alarms
5. Isolation of fire
6. Evacuation of immediate area
7. Evacuation of smoke compartment
8. Preparation of floors and building for evacuation
9. Extinguishment of fire.

Findings include:

Observations while reviewing drill paperwork September 17, 2020 reveled drill for the last three (3) years had been performed but not documented correctly. The drill documentation was not showing all the nine (9) items listed above the documentation of the completed drills only indicated a drill was conducted and who participated. The last two months a new drill format was implemented and had all the required components.

During the exit conference September 17, 2020 employees 2 and 9 indicated they were aware of and conformed the drill documentation was not showing all the nine (9) items listed above the documentation of the completed drills only indicated a drill was conducted and who participated. The last two months a new drill format was implemented and had all the required components

Based on observation, it was determined the facility failed to identify three (3) electrical conduit boxs that did not have an approved covers on them and uncapped conduit with wires protruding from the end. This could result in the wires making contact with combustible items and resulting in a fire.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.5.1.1 "Utilities shall comply with the provisions of Section 9.1." Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 'National Electrical Code" NEC, 2011. NFPA 70, Article 314, Section 314.28 "Boxes and conduit bodies used as pull or junction boxes shall comply with 314.28(A) through (E). Subsection (C) Covers. "All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Findings include:

Observations while on tour September 17, 2020 revealed the following:
1.Open juction box above the ceiling in the reception area
2.Open juction box above the ceiling in the Juniper Unit
3.Open conduit in the Juniper Unit stairwell


Employees # 1, 2 and 9 confirmed during the exit conference on September 17, 2020 the following:
1.Open juction box above the ceiling in the reception area
2.Open juction box above the ceiling in the Juniper Unit
3.Open conduit in the Juniper Unit stairwell

Based on Observation it was determined the facility did not allow access to the electrical equipment room electrical panels in the kitchen.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 2011 ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.
"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

Findings include:

Observations while on tour September 17, 2020 revealed blocked electrical panels and equipment in the kitchen area and IT room at the bottom of the long hallway.

Employee # 2 and 9 confirmed during the exit conference on September 17, 2020 the existence of blocked electrical panels and equipment in the kitchen area and IT room at the bottom of the long hallway.

Based on Observation it was determined the facility allowed the use of a multiple outlet adapters, power strips and extension cords and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

Observations while on tour September 17, 2020 revealed the following locations with power strips plugged into power strips (Daisy Chained). Use of extension cords as permanent equipment, multi plug adaptors without surge protection or heavy load drawing appliance (refrigerators, microwaves and large printers) plugged into power strips.
1. The front reception desk had a power strip daisy chained.
2. The Intake Room had a refrigerator plugged into a power strip.
3. The Administration offices have multiple examples of power strips daisy chained.
4. The Human Resources office had a refrigerator plugged into a power strip.
5. The Utilization Review room had a refrigerator plugged into a power strip and an extension cord plugged into a power strip.
6. The Juniper Unit had a power strip plugged daisy chained. refrigerator plugged into a power strip in the Director of Nursing office, a multi plug adapter without surge protection in the exam room and an extension cord in the TV room.
7. Multiple other locations had examples of the above listed items but were removed on the spot.

Employee # 1, 2 and 9 confirmed during the exit conference on September 17, 2020 the improper use of power strips, extension cords and multi plug adaptors without surge protection.

Based on Observation the facility failed to properly store full oxygen (O2) cylinders five (5) ft. from combustible items and to label the door indicating the hazard. This could result in the combustible items becoming oxygen saturated and easily ignitable which could cause a fire to start prematurely. Failing to label the door could result in personnel entering the area unaware of the hazards inside

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.4.1
A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.2.3
Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3)Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour

Findings include:

Observations while on tour September 17, 2020 revealed the following in the Juniper Unit storage room:
1. Three (3) full O2 cylinders being stored next to combustible materials.
2. The storage room door was not properly labeled indication oxygen was being stored inside.

During the exit conference on September 17, 2020 employee # 1and 2 acknowledged the following:
1. Three (3) full O2 cylinders being stored next to combustible materials in the Juniper Unit storage room, and the door was not properly labeled with the required verbiage.
2. The Juniper Unit storage room door was not properly labeled indicating oxygen storage.