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Based on observation and interview, the facility failed to maintain means of egress free of obstructions for instant use in an emergency. This deficient practice could delay exiting or block the path of egress from the facility.

Findings are:

Observations on 8/28/18 at 1:46 PM revealed:

1. The exit door at the bottom of northwest exit stairs in the Acute Wing was obstructed by a shovel and rug

2. The floor at the bottom of northwest exit stairs in the Acute Wing had heaved preventing the door from opening fully.

During an interview on 8/28/18 at 1:46 PM, Maintenance Director A confirmed the findings.

Based on observation, interview, and record review, the facility failed to provide emergency lighting of at least 1½-hour duration. This deficient practice could delay egress due to reduced illumination in an emergency.

Findings are:

Observation and record review on 8/28/18 at 2:00 PM., revealed that the battery emergency lighting units were not working properly in the acute generator room and did not work during the last four monthly checks.

On 8/28/18 at 2:00 PM, Maintenance A acknowledged the units were not working at the time of the inspection and had purchased two new units to replace the nonworking emergency lights.

Based on observation and interview, the facility failed to minimize the possibility of a fire in the facility by not ensuring that the stove top in Occupational Therapy was equipped with safety devices to prevent unauthorized use. This deficient practice increases the potential for the stove to be left on resulting in an accidental fire to start or burns to patients.

Findings are:
Observations on 8-28-18 at 2:50 pm revealed:
1. The cooktop in Physical Therapy was not in use for therapy. The power to the cook top was not turned off and when the control knobs were turned to the on position the burners got hot.
2. The facility failed to provide a lock-out switch to deactivate the power to the cook top when not in use.
3. The facility failed to provide a timer for the switch not exceeding a 120 minute capacity, which would automatically turn off power.
4. The facility failed to provide a procedure for the cook tops in the facility.

During an interview on 8-28-18 at 2:50 pm, Maintenance A confirmed the power to the cook top was not turned off and that the facility failed to provide a policy for the use of the cook top.

NFPA Standard:
2012, NFPA 101, 19.1.1.3.1
All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants.

19.3.2.5.2*
Where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the presence of the equipment shall not require the area to be protected as a hazardous area.

19.3.2.5.3*
Within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or fewer persons, one cooking facility shall be permitted to be open to the corridor, provided that all of the following conditions are met:
(1) The portion of the health care facility served by the cooking facility is limited to 30 beds and is separated from other portions of the health care facility by a smoke barrier constructed in accordance with 19.3.7.3, 19.3.7.6, and 19.3.7.8.
(2) The cooktop or range is equipped with a range hood of a width at least equal to the width of the cooking surface, with grease baffles or other grease-collecting and cleanout capability.
(3)*The hood systems have a minimum airflow of 500 cfm (14,000 L/min).
(4) The hood systems that are not ducted to the exterior additionally have a charcoal filter to remove smoke and odor.
(5) The cooktop or range complies with all of the following:
(a) The cooktop or range is protected with a fire suppression system listed in accordance with UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Commercial Cooking Equipment, or is tested and meets all requirements of UL 300A, Extinguishing System Units for Residential Range Top Cooking Surfaces, in accordance with the applicable testing document's scope.
(b) A manual release of the extinguishing system is provided in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 10.5.
(c) An interlock is provided to turn off all sources of fuel and electrical power to the cooktop or range when the suppression system is activated.
(6)*The use of solid fuel for cooking is prohibited.
(7)*Deep-fat frying is prohibited.
(8) Portable fire extinguishers in accordance with NFPA 96 are located in all kitchen areas.
(9)*A switch meeting all of the following is provided:
(a) A locked switch, or a switch located in a restricted location, is provided within the cooking facility that deactivates the cooktop or range.
(b) The switch is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision.
(c) The switch is on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cooktop or range, independent of staff action.
(10) Procedures for the use, inspection, testing, and maintenance of the cooking equipment are in accordance with Chapter 11 of NFPA 96 and the manufacturer's instructions and are followed.
(11)*Not less than two AC-powered photoelectric smoke alarms, interconnected in accordance with 9.6.2.10.3, equipped with a silence feature, and in accordance with NFPA 72, National Fire Alarm and Signaling Code, are located not closer than 20 ft (6.1 m) from the cooktop or range.
(12) No smoke detector is located less than 20 ft (6.1 m) from the cooktop or range.
(13) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

Based on observation and staff interviews, the facility did not ensure that corridor separation doors would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke between 2 of 15 smoke zones affecting approximately 15 occupants.

Findings are:
Observation on 8/28/18 at 3:15 P.M., revealed the smoke separation doors by the occupational Therapy Office did not close completely when released from the open position.

Interview on 8/28/18 at 3:15 P.M., with Maintenance A confirmed the doors were not closing properly.

Based on observation, and staff interview, the facility failed to use electrical equipment as permitted by CMS regulations in Patient Use areas. This condition created the potential of an electrical fire, which would affect approximately 5 occupants in the occupation therapy corridor which is one of 15 smoke compartments.

Findings are:

Observation on 8/28/18, at approximately 3:00 P.M. revealed a power strip that did not meet UL 1363 was being used in the waiting area of occupation therapy corridor with other than medical equipment plugged into it.

During an interview on 8/28/18, at 3:00 P.M. Maintenance A confirmed the use of the electrical power strip.