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Tag No.: K0293
Based on observation and staff interview, the facility failed to maintain and/or install proper exit signage under NFPA 101 (2012 edition), Life Safety Code sections 19.2.10.1, 7.10.1.2.2, 7.10.8.3, 7.10.8.31 and 7.10.8.3.2. This deficient finding could have a patterned impact on the patients within the facility.
Findings include:
On 01/22/2024 between 10:00 AM and 12:00 PM, it was revealed by observation that the two sets of double doors leading to the center courtyard area, located outside the serving kitchen (room number 1123) were missing a "NO EXIT" sign.
An interview with the Physical Plant Director verified this deficient finding at the time of discovery.
Tag No.: K0353
Based on observation and staff interview, the facility failed to maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.2.2.2. This deficient finding could have an isolated impact on the patients within the facility.
Findings include:
On 01/22/2024 at 10:49 AM, it was revealed by observation that there were wires wrapped around and laying on the sprinkler pipes located above the ceiling near room E021 Staff Lounge.
An interview with the Physical Plant Supervisor verified this deficient finding at the time of discovery.
Tag No.: K0363
Based on observation and staff interview, the facility failed to maintain corridor doors per NFPA 101 (2012 edition), Life Safety Code, section 19.3.6.3.10. These deficient findings could have an isolated impact on the patients within the facility.
Findings include:
1. On 01/22/2024 between 10:00am and 12:00pm, it was revealed by observation that the corridor door leading to the breakroom in the first level maintenance corridor was being propped open with a metal wedge device.
2. On 01/22/2024 between 10:00am and 12:00pm it was revealed by observation that the doors leading to the following first level maintenance corridor offices were being propped open with metal wedge devices: Office 1017, Office 1046, and Office 1016A.
3. On 01/22/2024 between 10:00am and 12:00pm, it was revealed by observation that the corridor door leading to the Boiler Room in the first level maintenance corridor was being propped open with a metal wedge device.
An interview with the Physical Plaint Director verified these deficient findings at the time of discovery.
Tag No.: K0920
Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. These deficient findings could have a patterned impact on the patients within the facility.
Findings include:
On 01/22/2024 between 10:00 AM and 12:00 PM, it was revealed by observation that there were several electrical appliances plugged into power strips in the following areas:
1) Quality Office near the front desk area
2) Workroom 2066 on the counter surface on back wall
3) Physical Plant Directors office (Office 1016A)
An interview with the Physical Plant Director verified these deficient findings at the time of discovery.