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Based on observation and interview, the facility failed to provide a level walking surface in the path of egress in accordance with the requirements of NFPA 101 (2012 edition), 7.1.6 and 7.1.7. These deficient practices could affect all 16 patients and an undetermined number of staff and visitors.

Findings include:

1. On 01/27/20 at 2:42 pm, observation in the exit discharge from the northwest wing revealed a 5 foot x 8 foot wide concrete stoop with adjacent concrete sidewalk with at least a 1 inch difference in elevation between the two surfaces.

2. On 01/27/20 at 2:45 pm, observation in the exit discharge from the west wing revealed a 5 foot x 8 foot wide concrete stoop with adjacent concrete sidewalk with at least a 1 inch difference in elevation between the two surfaces.

These deficient practices were confirmed by Staff J at the time of discovery.

Based on observation and staff interview, the facility did not ensure that the fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 101 (2012 edition), Sections 19.3.4 and 9.6.1, NFPA 70, National Electric Code (2011 edition), and NFPA 72, National Fire Alarm and Signaling Code (2010 edition) Section 14.4.5.3, 14.4.5.3.1 and 14.4.5.3.2. This deficient practice could affect all 16 patients and an undetermined number of staff and visitors.

Findings include:

On 01/27/2020 at 2:38 pm, observation revealed that the fire alarm panel located at the nurses station indicated the incorrect time on the alarm system panel. The time indicated was approximately 1 hour ahead of the actual time.

This deficient practice was confirmed by Staff J at the time of discovery.

Based on observation and interview, the facility did not provide and maintain fire barrier door assemblies that meet code requirements for separation of fire areas, in accordance with the requirements of NFPA 101 (2012 edition.), 8.3.3. This deficient practice could affect an undetermined number of patients, staff and visitors.

Findings include:

On 01/27/2020 at 2:00 pm, observation revealed that the double fire doors connecting the hospital portion of the facility with the administrative core at a 2-hour fire wall did not meet the requirements for the required fire door. The glass area of the doors exceed allowable area and multiple penetrations of the door leaves and frame where hardware changes have occurred existed.

This deficient practice was confirmed by Staff J at the time of discovery.

Based on record review and interview, the facility did not ensure HVAC systems were maintained in accordance with NFPA 101 (2012 edition) Sections 19.5.2.1, 9.2.1; NFPA 90A (2012 edition), 5.4.8.1, 5.4.8.2; NFPA 80 (2010 edition) 19.4.1, 19.4.1.1 and NFPA 105 (2010 edition), 6.5.2. This deficient practice could affect all 16 patients and an undetermined number of staff and visitors.

Findings include:

On 01/27/2020 at 12:30 pm, record review revealed that the facility had no record of fire and smoke damper six year functional testing requirements.

This deficient practice was confirmed by Staff J at the time of discovery.

Based on observation and interview, the facility failed to test electrical receptacles in accordance with the requirements of NFPA 99 - 2012 edition, Section 6.3.3.2, 6.3.3.2.1, 6.3.3.2.2, 6.3.3.2.3, 6.3.3.2.4 and 6.3.4. This deficient practice could affect all 16 patients and an undertermined number of staff and visitors.

Findings include:

On 01/27/20 at 12:40 pm, observation revealed that there were hospital grade outlets located in the resident rooms. Interview with Staff J revealed that the facility had no documentation of the continuity of ground in circuit, polarity or retention testing of the electrical outlets when they were initially installed.

This finding was confirmed by Staff J at the time of discovery.