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Based on observation, a review of available documentation, and staff interview, the facility failed to install the required safety features for cooking equipment per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.5.3 (9) and 19.3.2.5.4. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that the residential stove located in physical therapy was not equipped with a lock-out switch and was not on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cook-top or range, independent of staff action.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain spacing between storage and the 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 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility.

Findings include:

On 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in:

1) Information Technology (IT) Office
2) Data Room
3) Dish Washing Area in Kitchen


An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain corridor doors per NFPA 101 (2012 edition), Life Safety Code, section 19.3.6.3.5. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that the room door B121 does not latch.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that there was a penetration running from one smoke compartment to another above doors in the following areas;

1) A145 Doors
2) A201 2 Hour Fire Wall
3) A229 2 Hour Fire Wall

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to secure electrical panels per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.3.2.2.1.3 and failed to maintain the Gas and Utility System per NFPA 101 (2012 edition), Life Safety Code section 9.2.2 and NFPA 54 (2012 edition), National Fuel Gas Code, sections 9.2.2 and 10.3.2.2. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that the electrical panels located in the following areas were not locked.

1) Panel D
2) Panel C
3) Panel CR101
4) Panel L101

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills under varied times and conditions per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.1.6, 4.7.4, and 4.6.1.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

1. On 08/27/2024, between 9:00am and 1:30pm, it was revealed by a review of available documentation that fire drills did not meet the varying time requirement: second shift 02/08/2024 at 4:00 PM, 05/08/2024 at 4:33 PM, and 08/09/2024 at 3:05 PM.

2. On 08/27/2024, between 9:00am and 1:30pm, it was revealed by a review of available documentation that fire drills were not completed: first shift missing, third quarter (July - September) and first quarter (July - September) drills completely.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct the electrical testing and maintenance per NFPA 99 Standards for Health Care Facilities 2012 edition, section 6.3.3.2, 6.3.4.1.3, and 6.3.4.2.1.2. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 08/27/2024, between 9:00am and 1:30pm, it was revealed by review of available documentation the required annual receptacle inspection documentation was not available at the time of the survey.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

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. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in in the following areas

1) Human Resourses Office
2) Laundry Room
3) Culanary Office

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to store oxygen cylinders per Health Care Facilities Code NFPA 99 (2012 Edition), sections 5.1.3.2, 5.1.3.3.4, 11.3.2.3, 11.6.5.2 and 11.6.5.3. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/27/2024, between 9:00am and 1:30pm, it was revealed by observation that the facility oxygen storage room does not have a vent system.

An interview with the Environmental Services Director verified these deficient findings at the time of discovery.