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Based on observation and staff interview, it was determined the facility failed to ensure that hazardous area doors be self-closing or automatic-closing. Failing to maintain the the self-closing hardware on the door and frame to a hazardous room has potential harm to patients in time of a fire if the door does not latch and close.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing."

Findings Include:

Observation on tour conducted on July 18, 2019, revealed the hazardous area doors were not self-closing or automatic-closing in the oxygen storage room door and the dry storage room door in the kitchen.

The Director of Risk/PIand the Director of A&R acknowledged during the exit conference on July 18, 2019, that the hazardous area doors were not self-closing or automatic-closing in the oxygen storage room door and the dry storage room door in the kitchen.

Based on observation and interview with staff, it was determined that the facility failed to maintain the sprinkler heads in multiple areas within the facility. Failing to maintain sprinkler heads poses potential harm to patients and staff by allowing a fire to spread before the temperature is reached to set off the sprinkler head.

NFPA 101 Life Safety Code, 2012 edition, Chapter 19, Section 19.3.5.1 "Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage."

Findings Include:

Observation on tour conducted on July 18, 2019 revealed sprinkler heads with dust/lint on the sprinkler heads in the following locations:

1. Conference room, 4 sprinkler heads with dust/lint.
2. Administration hallway, 5 sprinkler heads with dust/lint.
3. Kitchen, 5 sprinkler heads with dust/lint.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 18, 2019, that there was dust/lint on the sprinkler heads.

Based on observation and interview with staff, it was determined the facility failed to ensure 3 feet of working space was present around the electric water heater. Failing to ensure proper spacing around electrical equipment in the event of equipment failure, could potentially cause a delay with servicing the equipment, and poses potential harm to staff and patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1.1 "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2" "Electrical wiring and equipment shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction." NEC, 2011 ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions."

"(NO STORAGE ALLOWED IN THE WORKING SPACE)"

Findings include:

Observation on tour conducted on July 18, 2019, revealed a storage rack in the kitchen blocking access to the electric water heater. The storage rack contained pots and pans, which potentially affords lack of the ability for staff not to be able to move the rack in time of an emergency.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 18, 2019, that there was a storage rack in the kitchen blocking access to the electric water heater.

Based on record review and interview with staff, it was determined that there was missing fire drill documentation. Failing to conduct the fire drills in accordance with the life safety code to familiarize staff with conditions under an actual fire poses potential harm to patients and staff during an actual fire or emergency situation.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 "Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions."

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.2.2 "Written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Emergency phone call to the fire department
4. Response to alarms
5. Isolation of fire
6. Evacuation of immediate area
7. Evacuation of smoke compartment
8. Preparation of floors and building for evacuation
9. Extinguishment of fire."

Findings include:

The requested fire drill documentation was reviewed on July 18, 2019. The following required quarterly fire drill documentation was missing:

1. Second shift, second, third, and fourth quarters of 2018.
2. First and second shift, second quarter of 2019.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 18, 2019, that there was no documentation to review for the second shift, second, third, and fourth quarters of 2018 and first and second shift, second quarter of 2019.

Based on record review and interview with staff, it was determined the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's." Failing to inspect and test fire rated door assemblies in accordance with NFPA 80 annually could cause potential harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code."

NFPA 80 Section 5.2* Inspections Section 5.2.1* "Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing."

NFPA 80 Section 13.4 Automatic closing Section 5.2.5 Horizontal sliding , Vertically Sliding, and Rolling Doors.
Section 5.2.14.3 "All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation."

Findings include:

The annual fire rated door assembly records were requested on July 18, 2019. The facility did not have written records of the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's for 2018.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 18, 2019, that there was no documentation to review of the annual fire rated door assemblies for 2018.

Based on record review and interview with staff, it was determined that the facility failed to conduct, maintain and document electrical receptacle testing in all patient care areas annually throughout the facility. Failing to test and document annually the receptacle testing of all patient care areas of the facility could lead to an ignition hazard in a patient care area potentially causing a fire and or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction." NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.3 "Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months."

Findings include:

The receptacle testing documentation was requested on July 18, 2019. There was no documentation available for review provided for receptacle testing in patient care areas for 2018.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 18, 2019, that there was no documentation to review for receptacle testing in patient care areas for 2018.

Based on observation and staff interview, it was determined the facility failed to ensure that appliances are directly plugged into wall outlet receptacles and not power strips. The use of multiple outlet adapters could create an overload of the electrical system, and could cause a fire or an electrical hazard. A fire has potential harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 "The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code." Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters."

Findings include:

Observation on tour conducted on July 18, 2019, revealed a refrigerator plugged into a power strip and not directly plugged in to the receptacle wall outlets in the Palo Verde breakroom.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 18, 2019, that there was a refrigerator plugged into a power strip and not directly plugged in to the receptacle wall outlets in the Palo Verde breakroom.

Based on observation and staff interview, it was determined the facility failed to keep combustible material 5 ft away from oxygen storage. Failure to keep combustible material away from oxidizing gases could cause an increase to the fire load, which has potential harm to staff and patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.3.2.3 "Oxidizing gases, such as oxygen and nitrous oxide shall be separated from combustibles materials by one of the following:

(1) Minimum distance 20 feet
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
93) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour."

Findings included:

Observation on tour conducted on July 18, 2019, revealed the storage of combustible material within 5 ft of oxygen storage room.

The Director of Risk/PI and the Director of A&R acknowledged during the exit conference on July 18, 2019, that there was combustible material within 5 ft of oxygen storage room.