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Based on observation and interview, the facility failed to ensure 1 of 8 exit discharges were continuously maintained free of obstruction to full use in case of emergency. This deficient practice could affect 20 patients, staff and visitors if needing to exit the facility from the north courtyard.

Findings include:

Based on observations with the Director of Plant Operations (DPO) and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, the door in the fence in the north courtyard exit discharge path had no handle or push bar or any other device to push or pull the courtyard fence door open. After unlocking the deadbolt on the courtyard fence door, the DPO could not open the door within three minutes due to the door being stuck in the closed position. After three minutes of attempting to open the door, the DPO was able to open the door. Based on an interview at the time of the observations, the DPO acknowledged the north courtyard discharge was not maintained free of obstruction to full use in case of emergency.

1. Based on observation and interview, the facility failed to ensure 1 of 1 exit discharge stairs was provided with handrails. LSC 7.2.2.4.1.1 states stairs shall have handrails on both sides, unless otherwise complying with 7.2.2.4.1.5 or 7.2.2.4.1.6. This deficient practice could affect 20 patients, staff and visitors if needing to exit the facility from the north courtyard exit discharge stairs.

Findings include:

Based on observations with the Director of Plant Operations (DPO) and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, the exit discharge stairs from the north courtyard to the public way consisted of five steps over the length of the exit discharge and was not provided with handrails. Based on interview at the time of observation, the DPO acknowledged the aforementioned exit discharge stairs were not provided with handrails.

2. Based on observation and interview, the facility failed to ensure 1 of 1 exit discharge stairs was free of projections or lips that could trip stair users in accordance with LSC 7.2.2.3.3.2. This deficient practice could affect 20 patients, staff and visitors if needing to exit the facility from the north courtyard exit discharge stairs.

Findings include:

Based on observations with the Director of Plant Operations (DPO) and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, the exit discharge stairs from the north courtyard to the public way consisted of five steps and landings which were each constructed of paver stones laid and contained within the rectangular framework of wooden landscaping rails. The paver stones settled over time which caused the paver stones to not be level with the landscape rails causing trip hazards over the entire length of the exit discharge stairs to the public way. Based on interview at the time of the observations, the DPO acknowledged the paver stones at the aforementioned exit discharge stairs settled over time which caused the landscape rails to be a trip hazard over the entire length of the exit discharge stairs to the public way.

Based on observation and interview, the facility failed to ensure 1 of 1 exit ramps was provided with handrails. LSC 7.2.5.4.2 states handrails complying with 7.2.2.4 shall be provided along both sides of a ramp run with a rise greater than 6 inches, unless otherwise provided in 7.2.5.4.4. This deficient practice could affect 10 patients, staff and visitors if needing to exit the facility from the first floor Dining Room.

Findings include:

Based on observation with the Director of Plant Operations (DPO) and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, the exterior ramp serving as the exit discharge to the public way from the first floor Dining Room had a rise of three feet over the 52 foot length of the ramp and was not provided with handrails. Based on interview at the time of observation, the DPO acknowledged the aforementioned exterior ramp was not provided with handrails.

1. Based on record review, observation and interview; the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on review of Koorsen Fire & Security "Inspection and Test Report" documentation dated 04/25/16, 07/19/16, 09/27/16 and 01/04/17 with the Director of Plant Operations (DPO) and Maintenance Technicians I and II from 10:20 a.m. to 2:30 p.m. on 03/27/17, documentation of quarterly sprinkler system inspection for the fourth quarter (October, November, December) 2016 was not available for review. Based on interview at the time of record review, the DPO stated Koorsen could not perform a fourth quarter 2016 inspection due to scheduling conflicts and acknowledged written documentation of fourth quarter 2016 sprinkler inspection was not available for review. Based on observations with the DPO and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, Koorsen had affixed hanging tags to the sprinkler system risers documenting sprinkler inspections none of which included a fourth quarter 2016 inspection.

2. Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.2.4.2 states gauges on preaction systems shall be inspected weekly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on review of Koorsen Fire & Security "Inspection and Test Report" documentation dated 04/25/16, 07/19/16, 09/27/16 and 01/04/17 with the Director of Plant Operations (DPO) and Maintenance Technicians I and II from 10:20 a.m. to 2:30 p.m. on 03/27/17, monthly wet sprinkler system gauge inspection documentation for 8 months of the most recent 12 month period was not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 8 months of the most recent 12 month period was also not available for review. Based on interview at the time of record review, the DPO stated the facility performs visual sprinkler system inspections at regular intervals but does not document sprinkler system gauge and system control valves inspections and acknowledged sprinkler system gauge and control valve inspection documentation for the aforementioned monthly periods was not available for review. Based on observations with the DPO and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, the facility has a supervised wet sprinkler system and had a total of four water pressure gauges.

3. Based on observation and interview, the facility failed to ensure the supply of spare sprinklers maintained on the premises corresponded to the types and temperature ratings of the sprinklers in the property. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on observations with the DPO and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, sidewall sprinklers were observed installed in the elevator shaft and outside the facility at the loading dock. No sidewall spare sprinklers were noted in the spare sprinkler cabinet in the sprinkler riser room or on the premises. Based on interview at the time of the observations, the DPO acknowledged no sidewall spare sprinklers were in the spare sprinkler cabinet or on the premises.

Based on record review and interview, the facility failed to document activation of the fire alarm system for first and second shift fire drills conducted between 6:00 a.m. and 9:00 p.m. for 1 of 4 quarters. LSC 19.7.1.4 states fire drills in health care occupancies shall include the transmission of the fire alarm signal and simulation of emergency fire conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on review of "Fire Drill Report" documentation with the Director of Plant Operations (DPO) and Maintenance Technicians I and II from 10:20 a.m. to 2:30 p.m. on 03/27/17, documentation for the first shift fire drill conducted on 08/23/16 at 6:30 a.m. indicated the drill was conducted after 6:00 a.m. but before 9:00 p.m. and did not include activation of the fire alarm system and transmission of the fire alarm signal. The aforementioned first shift fire drill documentation stated "Did not activate system\In-service questions" in response to "Alarm Company Notified At (Time)." In addition, documentation for the second shift fire drill conducted on 01/30/17 at 5:00 p.m. indicated the drill was conducted after 6:00 a.m. but before 9:00 p.m. and also did not include activation of the fire alarm system and transmission of the fire alarm signal at the time of the fire drill. The aforementioned second shift fire drill documentation stated "9:58 a.m. on 01/31/17" in response to "Alarm Company Notified At (Time)." Based on interview at the time of record review, the DPO acknowledged documentation for the aforementioned first and second shift fire drills conducted after 6:00 a.m. but before 9:00 p.m. did not include activation of the fire alarm system and transmission of the fire alarm signal.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after monthly load tests for 12 of 12 months. Chapter 6.4.4.1.1.4(A) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 2010 Edition, Section 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. NFPA 110, Section 8.3.4 states a permanent record of the Emergency Power Supply Systems (EPSS) inspections, tests, exercising, operation, and repairs shall be maintained and readily available. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Monthly Generator Load Test" documentation with the Director of Plant Operations (DPO) and Maintenance Technicians I and II from 10:20 a.m. to 2:30 p.m. on 03/27/17, documentation for monthly load tests conducted within the most recent twelve month period did not include cool down time for each of the monthly load tests. Based on interview at the time of record review, the DPO stated the emergency generator is load tested monthly for at least one half hour with an additional cool down time period but acknowledged cool down time was not recorded for the aforementioned twelve month period. Based on observation with the (DPO) and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, manufacturer's nameplate information affixed to the emergency generator located outside the facility indicated it was rated at 400 kW.

Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage areas was in accordance with NFPA 99 Health Care Facilities Code. NFPA 99, 2012 Edition, Section 11.3.1 states storage for nonflammable gases equal to or greater than 3000 cubic feet shall comply with 5.1.3.3.2 and 5.1.3.3.3. Section 5.1.3.3.2 states, if indoors, storage locations of positive-pressure gases shall be constructed and use interior finishes of noncombustible or limited combustible materials such that all walls, floor, ceilings, and doors are of minimum 1-hour fire resistant rating. This deficient practice could affect five patients, staff and visitors in the vicinity of the oxygen storage and transfilling room on the first floor.

Findings include:

Based on observations with the Chief Executive Officer (CEO), the Director of Plant Operations (DPO) and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, the following was noted at the oxygen storage and transfilling room on the first floor:
a. the corridor entry door was equipped with a self-closing device but had no affixed fire resistance rating label or fire resistant rating documentation available for review.
b. the room was not mechanically vented and did not have ceramic or concrete flooring.
Two liquid oxygen containers were stored in the room as well as six 'E' type oxygen cylinders. In addition, observation with Maintenance Technicians I and II at 10:45 a.m. on 03/28/17 noted a six inch in diameter hole in the corridor wall above the suspended ceiling above the corridor entry door to the room which also did not enclose the room with 1 hour fire resistive construction. Based on interview at the time of the observations, the CEO, DPO and Maintenance Technicians I and II acknowledged the aforementioned observations.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 oxygen storage locations where transfilling occurs was in accordance with NFPA 99, Health Care Facilities Code. NFPA 99, 2012 Edition, Section 11.5.2.3.1 states oxygen transfilling locations shall include the following:
(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire resistive construction.
(2) The area is mechanically vented, is sprinklered, and has ceramic or concrete flooring.
(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.
(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures.
Section 11.5.3.2.3 states in health care facilities where smoking is prohibited and signs are prominently (strategically) placed at all major entrances, secondary signs with no smoking language shall not be required. This deficient practice could affect five patients, staff and visitors in the vicinity of the oxygen storage and transfilling room on the first floor.

Findings include:

Based on record review with the Director of Plant Operations and Maintenance Technicians I and II from 10:20 a.m. to 2:30 p.m. on 03/27/17, assessed patients are allowed to smoke in designated outdoor areas. Based on observations with the Chief Executive Officer (CEO), the Director of Plant Operations (DPO) and Maintenance Technicians I and II during a tour of the facility from 8:45 a.m. to 11:05 a.m. on 03/28/17, the following was noted at the oxygen storage and transfilling room on the first floor:
a. the corridor entry door was equipped with a self-closing device but had no affixed fire resistance rating label or fire resistant rating documentation available for review.
b. the room was not mechanically vented and did not have ceramic or concrete flooring.
c. the area was not posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.
Two liquid oxygen containers were stored in the room as well as six 'E' type oxygen cylinders. In addition, observation with Maintenance Technicians I and II at 10:45 a.m. on 03/28/17 noted a six inch in diameter hole in the corridor wall above the suspended ceiling above the corridor entry door to the room which also did not enclose the room with 1 hour fire resistive construction. Based on interview at the time of the observations, the CEO, DPO and Maintenance Technicians I and II acknowledged the aforementioned observations.