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1. Based on observation and staff interview, the facility failed to maintain doors with self-closing devices in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain doors with self-closing devices as required could result in injury or death during an emergency. The deficiency affected two (2) of numerous doors with self-closing devices. The findings were:

Observation on 4/26/2022 at 8:29 AM at the west storage door revealed the self-closing door was held open with a heavy object. Further observation at the kitchen storage self-closing door found that its door handle wrapped around the rooms shelving holding the door ajar. Interview with kitchen staff found that the door is kept open as described during the day and is closed at night.

Interview with the maintenance manager at the time of observation acknowledged the doors being held open, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.2.2.2.1, 7.2.1.8.1

2. Based on observation and staff interview, the facility failed to maintain doors with self-closing devices in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain doors with self-closing as required could result in injury or death during an emergency. The deficiency affected three (3) of numerous doors with self-closing devices. The findings were:

Observation on 4/26/2021 at 9:35 AM at the electrical mechanical room door revealed the the self-closing door failed to operate as designed. When dropped tested with no initial motion the door failed to shut and latch. Additional observation at 9:46 AM found the self-closing door separating the former waiting area (now office) from the corridor, found that the door failed to shut and latch when drop tested with no initial motion. Additional observation at 10:33 AM found the self-closing door separating the ambulance garage from the rear corridor unable to latch, due to missing hardware on the door frame.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.2.2.2.1, 7.2.1.8
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1. Based on observation and staff interview, the facility failed to maintain stairs in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain stairs as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of two (2) exits containing stairs from the facility. The findings were:

Observation on 4/26/2022 at 8:54 AM at the side/employee entrance/exit revealed the concrete stair structure, had degraded over time leaving the tread on one stair with 7 1/2" of tread depth at the minimum measurement.

Interview with the maintenance manager at the time of observation acknowledged that the depth of the stair tread was insufficient, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.2.2.3, 7.2.2, Table 7.2.2.2.1.1(b)

2. Based on observation and staff interview, the facility failed to maintain stair handrails in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain stair handrails as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of two (2) exits containing stairs from the facility. The findings were:

Observation on 4/26/2022 at 8:57 AM at the side/employee entrance/exit revealed that the stairway handrail was no longer attached to the ground, having rusted away. As an existing handrail, the handrail falls under the maintenance, inspection, and testing section of chapter 4, of the 2012 NFPA 101. Whereby any existing life safety feature shall be maintained.

Interview with the maintenance manager at the time of observation acknowledged that the handrail was no longer attached to the ground, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.2.2.3, 7.2.2, 7.2.2.4.4.9, 4.6.12.1, 4.6.12.2, 4.6.12.3
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Based on observation and staff interview, the facility failed to maintain exit discharge in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain exit discharge as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of five (5) exits from the facility. The findings were:

Observation on 4/26/2022 at 9:42 AM at the exit discharge leading from the old waiting room (currently an office), found a sign secured to both handrails at the bottom of the exit discharge stairs, that obstructed the pathway.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101; Sections: 19.2.7, 7.7.1, 7.7.4, 7.2.2, 7.1.10.1
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Based on observation and staff interview, the facility failed to maintain hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain hazardous areas as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of numerous rooms in the facility. The findings were:

Observation on 4/26/2022 at 9:20 AM in the central supply room revealed penetrations in the wall above the door to accommodate electrical conduit that had been sealed with calking in lieu of a UL listed fire-stop material.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101: Sections 19.3.2; 8.7.1; 8.3.5.1
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Based on observation and staff interview, the facility failed to maintain cooking areas in accordance with the 2012 NFPA 101, Life Safety Code and 2011 NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Failure to maintain cooking areas as required could result in injury or death during an emergency. The deficiency affected one (1) of one (1) kitchen in the facility. The findings were:

Observation on 4/26/2022 at 10:09 AM in the kitchen at the stove found that the new wheeled stove did not have a method of returning to the approved design location. No visible markings or wheel chocks were observed.

Interview with the facility maintenance at the time of observations acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections 19.3.2.5.1, 9.2.3
2011 NFPA 96, Sections 12.1.2.3, 12.1.2.3.1
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Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinklers. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency was in one (1) of numerous rooms. The findings were:

Observation on 4/26/2022 at the biohazard room revealed that the escutcheon had come loose and was blocking sprinkler head.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 13, Sections: 8.6.5
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Based on observation and staff interview, the facility failed to maintain sprinkler systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. The failure to maintain sprinkler systems as required could result in injury or death during an emergency. The deficiency affected one of numerous storage areas throughout the facility. The findings were:

Observation on 4/26/2022 at 8:37 in the west storage room revealed several items stacked within several inches of the sprinkler head, which resulted in an obstruction to the dispersion pattern of the affected sprinkler. Additional observation at 10:04 AM in the kitchen storage area revealed several items that were stacked to within several inches of the sprinkler head.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.3.5.1; 9.7.5
2011 NFPA 25, Section 5.2.1.2
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Based on observation and staff interview, the facility failed to provide access to fire extinguishers in accordance with the 2010 NFPA 10, Standard for Portable Fire Extinguishers, and the 2012 NFPA 101, Life Safety Code. Failure to provide access to a fire extinguisher as required may lead to injury or death during an emergency. The deficiencies affected one (1) of numerous fire extinguishers in the facility. The findings were:

Observation on 4/26/2022 at 8:39 AM in the west storage area along the west wall revealed a fire extinguisher that was blocked by storage.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101: Section 19.3.5.1.2, 9.7.4.1
2010 NFPA 10: Section 6.1.3.3.1
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Based on observation and staff interview, the facility failed to maintain electrical systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 70, National Electrical Code. The failure to maintain electrical systems as required could result in injury or death. The deficiency affected one (1) of numerous rooms in the facility. The findings were:

Observation on 4/26/2021 at 9:31 AM in the electrical/mechanical room revealed a duplex receptacle within six (6) feet of the sink, which was not protected by a ground fault circuit interrupter.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.5.1.1; 9.1.2
2011 NFPA 70, Section: 210.8(B)(5)
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Based on observation and staff interview, the facility failed to maintain elevators in accordance with the 2012 NFPA 101, Life Safety Code. The failure to maintain elevators as required could result in injury or death during an emergency. The deficiency affected one (1) of one (1) elevators. The findings were:

Interview on 4/25/22 at 4:30 PM with the maintenance manager revealed that the monthly testing of the elevator fire fighter recall system had not been completed. Further interviews revealed the elevator does not move more than 25 ft, but is equipped with a fire fighter recall system.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101: Sections: 19.5.3, 9.4.6.2, 4.6.12.1, 4.6.12.4
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1. Based on observation and staff interview, the facility failed to maintain fire-rated doors and frames in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. The failure to maintain fire-rated doors and frames as required could result in injury or death in an emergency. The deficiency affected one (1) of numerous fire-rated doors and frames throughout the facility. The findings were:

Observation on 4/26/2022 at 8:29 AM of the west storage corridor door revealed a hole that penetrated through the rated storage door frame.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101, Sections: 19.7.6; 4.6.12, 7.2.1.15.2
2010 NFPA 80, Section 5.2.4.2(1)

2. Based on observation and staff interview, the facility failed to maintain fire-rated doors and frames in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. The failure to maintain fire-rated doors and frames as required could result in injury or death in an emergency. The deficiency affected one (1) of numerous fire-rated doors and frames throughout the facility. The findings were:

Observation on 4/26/2022 at 9:20 AM at the central supply room door revealed that the UL listing frame tag had been painted over. .

Interview with the maintenance manager at the time of observation acknowledged the missing tag, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.2.2.5, 7.2.4.3.1, 8.3.3.1, 8.3.3.2, 8.3.3.2.2
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Based on observation and staff interview, the facility failed to provide portable space heaters in accordance with the 2012 NFPA 101, Life Safety Code. The failure to provide portable space heaters as required could result in injury or death due to an increased risk of fire. The deficiency affected one (1) of multiple rooms in the facility. The findings were:

Observation on 4/26/2022 at 10:14 AM in the dining room revealed a portable space heater. The space was labeled as "staff only", but interview revealed that residents do eat within the space upon approval of their attending physician. No documentation was available to determine the maximum temperature of the heating elements.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101, Section 19.7.8
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Based on observation and staff interview, the facility failed to maintain corridor separations in accordance with the 2012 NFPA 101, Life Safety Code. The failure to maintain corridor separations as required could result in injury or death due in an emergency. The deficiency affected one (1) smoke compartment in the facility. The findings were:

Observation on 4/26/22 at 10:41 AM in the medical gas storage and manifold room revealed that the room had no ventilation provided within one foot of the floor. Per NFPA 99, ventilation must be provided either per natural ventilation including two (2) openings within one foot of the floor and ceiling, or via mechanical ventilation with an inlet drawing from within one foot of the floor.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 99, Sections: 9.3.7.5; 9.3.7.5.2, 9.3.7.5.3
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Based on observation and staff interview, the facility failed to maintain the vacuum pump room in accordance with the 2012 NFPA 99, Life Safety Code. The failure to maintain the vacuum pump room as required could result in injury or death in an emergency. The deficiency affected one (1) of one (1) vacuum pump enclosures in the facility. The findings were:

Observation on 4/26/22 at 10:25 AM in the vacuum pump room revealed that the facility was storing dirty linen inside of the room. NFPA 99 requires medical-surgical vacuum sources to be in a dedicated mechanical equipment area

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 99, Section 5.1.3.7.1.1(1)
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Based on observation and staff interview, the facility failed to maintain electrical systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2011 NFPA 70, National Electrical Code. The failure to maintain electrical systems as required could result in injury or death. The deficiency affected one (1) of numerous electrical equipment rooms in the facility. The findings were:

Observation on 4/26/2021 at 9:31 AM in the electrical/mechanical room revealed multiple obstructions in front of the electrical breaker panels. A working space of three (3) feet in front of the panels is to be maintained.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.5.1.1; 9.1.2
2011 NFPA 70, Section: 210.8(B)(5)
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Based on observation and staff interview, the facility failed to maintain electrical equipment in accordance with the 2012 NFPA 101, Life Safety Code and the 2011 NFPA 70 National Electrical Code. The failure to maintain electrical equipment as required could result in injury or death. The deficiency affected two (2) of numerous rooms in the facility. The findings were:

Observation on 4/26/2022 at 9:17 AM in Central Storage revealed that a power strip was plugged into an extension cord. Additional observation at 10:20 AM in the front of the business office found a power strip plugged into a power strip, creating a daisy chain.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the director of nursing at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101, Section 9.1.2
2011 NFPA 70, Section 400.8