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Based on visual observation the facility failed to provide corridor doors that were smoke resistive and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants and the egress corridor deficient practice has the potential to affect 9 of 9 patients.

Findings:

During the facility tour, between the hours of 10:00 am and 12:30 pm the medication room dutch door was observed not being smoke resistive, the housekeeping storage door closure was not adjusted to make the door latch. Also door stops were observed on the material management and office suite doors.

Based on visual observation the facility failed to provide exit signage above closed cross corridor doors. Exit signs provide a route for occupants to reach safety. This deficient practice has the potential to affect 9 of 9 patients.


Findings:

During the facility tour, between the hours of 10:00 am and 12:30 pm the cross corridor solid wooden doors were observed having no exit signs installed to direct occupants from the patient care area and the out patient clinic to the outside exits on each end of the corridor.

Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice has the potential to affect of 9 of 9 patients.

Findings:

During tour of the facility, between the hours of 10:00 am and 12:30 pm the fire alarm test revealed the magnetic locks on 4 exit doors could be manually locked by staff from the remote release located at the nurse's station while the fire alarm was activated. Also, the staff working in the out patient clinic were not assigned keys to unlock the rear exit door and the cross corridor doors separating the hospital and clinic
When special locking devices are permitted one of three options is required in order to allow free egress for staff and visitors. The three options are:
1. The access code for the keypad is posted at the device, or,
2. The key to the override switch is posted at the device, or,
3. Staff carry a key to the override switch at all times.

Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice had the potential to affect 16 of 16 residents.

1 of 3 doors are deficient

Findings:

During the facility tour and activation of the fire alarm system it was observed that the patient entrance door with magnetic locking device relocked automatically when the fire alarm was reset. All doors with magnetic locking must be relocked manually.

When special locking devices are permitted one of three options is required in order to allow free egress for staff and visitors. The three options are:

1. The access code for the keypad is posted at the device, or,
2. The key to the override switch is posted at the device, or,
3. Staff carry a key to the override switch at all times

Interview with Program Director revealed the facility was not aware that the patient entrance was relocking when fire alarm was reset.

Based on visual observation required smoke detectors were not maintained, inspected and tested in accordance with the manufacturer's specifications in accordance with 9.6.1.3. This deficient practice could have the potential to cause harm to 9 of 9 patients.

Findings: Record review between the hours of 10:00 am and 12:30 pm revealed the facility did not have documentation showing sensitivity test had been performed on the smoke detectors by a licensed contractor. There were no other records for review.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 25. This deficiency has the potential to affect 9 of 9 patients.

Findings:

Record review during facility tour between the hours of 10:00 am and 12:30 pm revealed quarterly sprinkler inspections were being performed, however there was no record of the main drain having the required quarterly test and there was no documentation showing the gauges were tested monthly.

- Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. This deficient practice has the potential to affect 9 of 9 residents.

Findings:
During the facility tour, between the hours of 10:00 am and 12:30 pm the corridors were observed being used as a return air plenum for the HVAC unit. CMS and Fire Marshal will grant a temporary waiver for this deficiency, however the HVAC must shut down upon the activation of the fire alarm system and the corridor must be protected by a approved smoke detection system. These 2 requirements were not in place at the time of this inspection.

- Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions, in the egress corridor, hinder occupant egress in emergency situations. This deficient practice could potentially affect 9 of 9 patients in the facility.

Findings:

During the facility tour, between the hours of 10:00 am and 12:30 pm chairs and a table were observed obstructing the egress corridor in the out patient clinic.

- Based on visual observation and record review, the facility failed to assure the weekly inspection and a monthly testing program on the emergency generator were conducted and documented. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. This deficient practice has the potential to affect 9 of 9 residents.

Findings:

Record review, between the hours of 10:00 am and 12:30 pm revealed there was no documentation showing the required weekly generator runs. And the monthly required acid levels in the generator battery that are determined using a hydrometer were not documented . Also no "No Smoking" signs were observed on the generator and the propane tank.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. This deficiency has the potential to affect 9 of 9 residents.

Findings:

During the facility tour, between the hours of 10:00 am and 12:30 pm in the boiler/HVAC room multiple electrical junction boxes were observed with no cover plate. Also items were stored in front of the electrical panels.

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 0 of 9 residents. 1 of 3 smoke compartments were deficient.

Findings:

During the facility tour, between the hours of 12:00 and 1:00 it was observed that a glass reception opening had been cut in wall between corridor and Intake office making it not smoke resistive.

Interview with Program Manager revealed the facility was not aware that the opening was not allowed in the corridor walls that would allow the transfer of smoke from one room to another.

Based on visual observation the facility failed to provide corridor doors that were smoke resistive and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants and the egress corridor deficient practice has the potential to affect 9 of 9 patients.

Findings:

During the facility tour, between the hours of 10:00 am and 12:30 pm the medication room dutch door was observed not being smoke resistive, the housekeeping storage door closure was not adjusted to make the door latch. Also door stops were observed on the material management and office suite doors.

Based on visual observation the facility failed to provide exit signage above closed cross corridor doors. Exit signs provide a route for occupants to reach safety. This deficient practice has the potential to affect 9 of 9 patients.


Findings:

During the facility tour, between the hours of 10:00 am and 12:30 pm the cross corridor solid wooden doors were observed having no exit signs installed to direct occupants from the patient care area and the out patient clinic to the outside exits on each end of the corridor.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 0 of 16 residents.
1 of 3 smoke compartments have hazardous areas that are not separated.

Findings:

During the facility tour, between the hours 12:00 and 1:00 it was observed that the supply and the bio-hazard room doors need door closures.


Interview with Program Manage revealed the facility was not aware that the doors to the hazardous areas needed door closures.

Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice has the potential to affect of 9 of 9 patients.

Findings:

During tour of the facility, between the hours of 10:00 am and 12:30 pm the fire alarm test revealed the magnetic locks on 4 exit doors could be manually locked by staff from the remote release located at the nurse's station while the fire alarm was activated. Also, the staff working in the out patient clinic were not assigned keys to unlock the rear exit door and the cross corridor doors separating the hospital and clinic
When special locking devices are permitted one of three options is required in order to allow free egress for staff and visitors. The three options are:
1. The access code for the keypad is posted at the device, or,
2. The key to the override switch is posted at the device, or,
3. Staff carry a key to the override switch at all times.

Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice had the potential to affect 16 of 16 residents.

1 of 3 doors are deficient

Findings:

During the facility tour and activation of the fire alarm system it was observed that the patient entrance door with magnetic locking device relocked automatically when the fire alarm was reset. All doors with magnetic locking must be relocked manually.

When special locking devices are permitted one of three options is required in order to allow free egress for staff and visitors. The three options are:

1. The access code for the keypad is posted at the device, or,
2. The key to the override switch is posted at the device, or,
3. Staff carry a key to the override switch at all times

Interview with Program Director revealed the facility was not aware that the patient entrance was relocking when fire alarm was reset.

Based on visual observation required smoke detectors were not maintained, inspected and tested in accordance with the manufacturer's specifications in accordance with 9.6.1.3. This deficient practice could have the potential to cause harm to 9 of 9 patients.

Findings: Record review between the hours of 10:00 am and 12:30 pm revealed the facility did not have documentation showing sensitivity test had been performed on the smoke detectors by a licensed contractor. There were no other records for review.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 9 of 9 residents.

Findings:

During the facility tour, between the hours of 12:00 and 1:00 it was observed that an additional sprinkler head was need in the ice machine room located in the day room.

Interview with Program Manager revealed the facility was not aware the automatic sprinkler system was not complete, which was acknowledged by the Program Manager during the exit meeting.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 25. This deficiency has the potential to affect 9 of 9 patients.

Findings:

Record review during facility tour between the hours of 10:00 am and 12:30 pm revealed quarterly sprinkler inspections were being performed, however there was no record of the main drain having the required quarterly test and there was no documentation showing the gauges were tested monthly.

- Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. This deficient practice has the potential to affect 9 of 9 residents.

Findings:
During the facility tour, between the hours of 10:00 am and 12:30 pm the corridors were observed being used as a return air plenum for the HVAC unit. CMS and Fire Marshal will grant a temporary waiver for this deficiency, however the HVAC must shut down upon the activation of the fire alarm system and the corridor must be protected by a approved smoke detection system. These 2 requirements were not in place at the time of this inspection.

- Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions, in the egress corridor, hinder occupant egress in emergency situations. This deficient practice could potentially affect 9 of 9 patients in the facility.

Findings:

During the facility tour, between the hours of 10:00 am and 12:30 pm chairs and a table were observed obstructing the egress corridor in the out patient clinic.

- Based on visual observation and record review, the facility failed to assure the weekly inspection and a monthly testing program on the emergency generator were conducted and documented. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. This deficient practice has the potential to affect 9 of 9 residents.

Findings:

Record review, between the hours of 10:00 am and 12:30 pm revealed there was no documentation showing the required weekly generator runs. And the monthly required acid levels in the generator battery that are determined using a hydrometer were not documented . Also no "No Smoking" signs were observed on the generator and the propane tank.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. This deficiency has the potential to affect 9 of 9 residents.

Findings:

During the facility tour, between the hours of 10:00 am and 12:30 pm in the boiler/HVAC room multiple electrical junction boxes were observed with no cover plate. Also items were stored in front of the electrical panels.