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Based on document review and interview, it was determined that the facility failed to develop an Emergency Preparedness Plan that includes tracking the location of on-duty staff and residents, during an emergency or disaster event, in one of one plans.

Findings include.

Documentation review on April 26, 2018, at 12:30 p.m., revealed the facility lacked an Emergency Preparedness Plan that includes tracking the location of on-duty staff and residents, during an emergency or disaster event.

Interview with the Facilities Maintenance Manager and Fire Marshal on April 26, 2018, at 12:30 p.m., confirmed the facilities lack of a plan that includes tracking the location of on-duty staff and residents, during an emergency or disaster event.

Based on observation and interview, it was determined the facility had fire doors that lacked a fire resistance rating label on two of floors.

Findings include:

1. Observation on April 25, 2018 between 10:55 a.m. and 1:10 p.m., revealed the facility had fire doors that lacked fire resistance rating labels at the following locations:
A. Third floor, North Building, Second Section, fire doors, lacked a fire resistance rating label;
B. Second floor, North Building, Second Section, door 264, lacked a fire resistance rating label;
C. Third floor, South Building, between Second and Third Sections, fire doors, lacked a fire resistance rating label;
D. Second floor, South Building, Second Section, door 280, elevator lobby door, lacked a fire resistance rating label;
E. Second floor, South Building, First Section, fire door, by room 230, lacked a fire resistance rating label;
F. Third floor, IF Section, elevator lobby door, lacked a fire resistance rating label.

Interview with the Facilities Maintenance Manager on April 25, 2018, at 1:10 p.m., confirmed the above listed fire doors lacked fire resistance labels.

Based on observation and interview, it was determined doors in an exit passageway, stairway, or horizontal exit, smoke barrier or hazardous area that are self-closing and are not kept in the closed position on two of four floors.

Findings include:

1. Observation on April 25, 2018, between 10:35 a.m. and 1:30 p.m., revealed the facility had self-closing doors that lacked positive latching at the following locations:
A. Second floor, North Center Building, First Section smoke barrier doors, between rooms 237 and 238;
B. Third floor, North Center Building, First Section smoke barrier doors, between rooms 337 and 338;
C. Third floor, South Center Building First Section common wall door, between corridors 300 and 329;
D. Common wall door, at Three IF, lacked positive latching or closing with the self-closer.

Interview with the Facilities Maintenance Manager on April 25, 2018 at 1:30 p.m., confirmed the above listed self-closing doors lacked positive latching.

Based on observation and interview, it was determined that the means of egress, including exit discharge, was not capable of continous illumination at one of three exit discharges.

Findings include:

Observation on April 26, 2018, at 1:45 p.m., revealed the exit discharge, across from room 1118, lacked a two bulb system for illumination of the exit discharge.

Interview with the Facilities Maintenance Manager on April 26, 2018, at 1:45 p.m., confirmed the the exit discharge lacked a two bulb illumination system.

Based on observation and interview, it was determined that the facility failed to maintain corridor doors that resist the passage of smoke and shall be provided with a means suitable for keeping the door closed on one of four building levels.

Findings include:

1. Observation on on April 25, 2018, between 10:30 a.m. and 12:00 p.m., revealed the facility had corridor doors that lacked positive latching at the following locations:
A. Third floor, North Center Bldg., First Section, room 345, lacks positive latching
B. Second floor, South Center Bldg., First Section, room 217, lacks positive latching
C. Third floor, South Center Bldg., First Section, room 313, lacks positive latching
D. Third floor, South Center Bldg., First Section, room 347, lacks positive latching
E. Third floor, South Center Bldg., First Section, room 348, lacks positive latching
F. Second floor, North Center Bldg., First Section, room 245, lacks positive latching
G. Second floor, North Center Bldg., First Section, room 220, lacks positive latching

Interview with the Facilities Maintenance Manager on April 25, 2018, at 12:00 p.m., confirmed the above listed corridor doors lacked positive latching.

2. Observation on April 25, 2018, between 10:45 a.m. and 1:05 p.m., revealed the facility had corridor doors that had unsealed through the door penetrations at the following locations:
A. Third floor, North Center Building Second Section room 370 had unsealed corridor door penetrations;
B. Third floor North Center Bldg., Second Section, room 372, had unsealed corridor door penetrations;
C. Third floor, North Center Bldg., Second Section, room 394, had unsealed corridor door penetrations;
D. Third floor, North Center Bldg., Second Section, room 395, had unsealed corridor door penetrations;
E. Third floor, North Center Bldg., Second Section, room 383, had unsealed corridor door penetrations;
F. Third floor, North Center Bldg., Second Section, room 380, had unsealed corridor door penetrations;
G. Third floor, South Center Bldg., Second Section, dayroom 389, had unsealed corridor door penetrations.

Based on document review and interview, it was determined that the facility failed to perform fire drills as directed by regulations for the entire building.

Findings include:

Observation on April 26, 2018, at 11:30 a.m., revealed the facility's fire drill documentation was inconclusive in demonstrating fire drills were conducted at varied and unexpected times once per shift per quarter.

Interview with the Facilities Maintenance Manager and the Fire Marshal on April 26, 2018, at 11:30 a.m., confirmed the facility's fire drills inconclusive.

Based on document review and interview, it was determined that the facility failed to perform fire drills as directed by regulations for the entire building.

Findings include:

Observation on April 26, 2018, at 11:30 a.m., revealed the facility's fire drill documentation, was inconclusive in demonstrating fire drills were conducted at varied and unexpected times once per shift, per quarter.

Interview with the Facilities Maintenance Manager and the Fire Marshal on April 26, 2018, at 11:30 a.m., confirmed the facility's fire drills inconclusive.

Based on observation and interview, it was determined the facility failed to label doors where oxygen is in use on one of four floors.

Findings include:

Observation on April 25, 2018, at 11:10 a.m., revealed resident room 291, had an oxygen concentrator and lacked signage at the corridor door stating " No Smoking Oxygen in Use."

Interview with the Facilities Maintenance Manager on April 25, 2018, at 11:10 a.m., confirmed the use of oxygen without posting a warning sign.

Based on observation and interview, it was determined that the facility failed to inspect and maintain power cords, extension cord or outlet multipliers on one of four floors.

Findings include:

Observation on April 25, 2018, at 11:25 a.m., revealed the facility had a refrigerator plugged into a 3x1 adapter plug in the second floor, Computer Lab.

Interview with the Facilities Maintenance Manager on April 25, 2018, at 11:25 a.m., confirmed the utilization of a 3x1 adapter plug in the Computer Lab.