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Based on record review and interview, the facility failed to update, implement, and annually review emergency preparedness (EP) policies and procedures. This deficiency has the potential to affect all residents and staff of the facility.

Findings include:

1. A review of the facility EP program on 5/17/22 showed, the facility's EP programs policies and procedures had not been reviewed and revised since 3/24/21.

Based on record review, the facility failed to develop and implement emergency preparedness (EP) policies and procedures, addressing the use of volunteers. This affects all of the patients at the facility. Findings include:

1. Review of the facility EP program on 5/17/2022, showed the plan lacked information about the use of volunteers during an emergency.

Based on record review, the facility failed to develop policy and procedures related to the emergency and standby power systems for the EP plan. The record review showed insufficient information about the role of the emergency generator meeting care needs of the residents, the other occupants, as well as the building's needs based on the facility's safety and hazard vulnerability assessment. This deficiency affects all of the occupants in the facility.

Findings include:

1. Review of the EP plan on 5/17/2022 reflected a lack of specific details about what kind of services could be supported by the onsite emergency generator, i.e., the building temperatures, daily kitchen functions, safe food storage, illumination of the exit halls and exit signs, and the fire alarm, extinguishing and detection systems in the building.

Based on observations, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Section 18.2.2.3, 7.2.2.1.1, and 7.1.10.1.

Findings include:

1. During an observation on 5/17/2022 at 9:38 a.m., the stairwell exit to the clinic exit was inspected. There was a large pad lying in the path of egress in the stairwell. It was a pad to cover the large portion of the I-beam in the stairwell. It was supposed to be covering the bottom of the beam but kept coming off as the tacky material it was supposed to stick to would not hold it.

Based on observation, the facility failed to maintain the fire protection of hazardous rooms in accordance with NFPA 101, 2012 Edition, Section 18.2.2.2.7.

Findings include:

1. During an observation on 5/17/2022 at 10:15 a.m., the maintenance shop, which is considered a hazardous area, was inspected. The shop had a set of double doors to the corridor. One of the doors was found to be chocked open. The other door was found to be fitted with a self-closer with a sort of "detent" mechanism which allowed it to stay open when pushed open far enough. This hold-open mechanism was not connected to the fire alarm system.

2. During an observation on 5/17/2022 at 11:05 a.m., the Central Supply room was inspected. The room had a set of double corridor doors which were held open by self-closing devices which contained a kind of "detent" mechanism which would allow them to lock open. This mechanism is not connected to the buildings fire alarm system. Any kind of hold-open device on a hazardous room must be connected to the building fire alarm system so it will close the doors upon activation of the alarms.

3. During an observation on 5/17/2022 at 11:19 a.m., the laboratory, which is considered a hazardous area, was inspected. The lab had a self-closing door to the corridor. The door was found to be open, but was found to be fitted with a self-closer with a sort of "detent" mechanism which allowed it to stay open when pushed open far enough. This hold-open mechanism was not connected to the fire alarm system. Any kind of hold-open device on a hazardous room must be connected to the building fire alarm system so it will close the doors upon activation of the alarms.

Based on observation, the facility failed to address a long dead end corridor which could be confusing for occupants of the second floor in a fire in accordance with NFPA 101 2012 Edition, Section 18.2.5.2.

Findings include:

1. During an observation on 5/17/2022 at 10:55 a.m., the second level communicating space at the main entrance was inspected. It was a large area, open to both the main lobby up through the second story to the roof deck above. From the stairs going down to the main lobby area, around the upper level of the space, which ended at a wall, was measured to be 68 feet. This was a dead end corridor. Dead end corridors cannot be over 35 feet in length.

Based on observation, the facility failed to ensure exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface per NFPA 101-2012 Edition Section 18.2.7.

This deficiency affects the entire facility.

Findings include:

1. During an observation on 5/17/2022 at 9:37 a.m., the emergency exit called the clinic exit, providing egress outside of the building from an exit stairway and the clinic was inspected. The exit discharge did not have a hard surface path continuous to the public way.

2. During an observation on 5/17/2022 at 10:19 a.m., the egress from the south side of the building was inspected. The south nursing home exit, the south fire exit which includes the south stairway exit and the employee exit were found to not have a continuous hard surface pathway to the public way.

Based on observation, the facility failed to mark two paths of egress by approved exit or directional exit signs, in accordance with NFPA 101, 2012 Edition, Sections 7.10.1.2.1, and 7.10.1.2.2. These deficiencies affect 3 of 3 smoke compartments.

Findings include:

1. During an observation on 5/17/2022 at 10:40 a.m., the PT suite was inspected. The main PT area was inspected. There was an exit sign on the back wall with both chevrons punched out so it was pointing left and right. There was no exit door immediately left or right, which made the placement and directions of the exit sign to be quite confusing.

2. During an observation on 5/17/2022 at 12:30 p.m., the clinic was inspected. There was no exit sign viewable from both directions to the north exit in the clinic corridor. There were many doors in the corridor which would negate the way to the north exit from being obvious in a situation of darkness and/or smoke filled corridor.

Based on observations, the facility failed to ensure hazardous rooms which were protected in accordance with NFPA 101, 2012 Edition, Sections 18.3.2.1, 8.7 and 8.4.

Findings include:

1. During an observation on 5/17/2022 at 9:48 a.m., the janitor's closet numbered 2113 was inspected. There was a large 55 gallon paper bin in the room, thus making it a hazardous room. The corridor door would not close under the power of the self-closer.

2. During an observation on 5/17/22 at 9:50 a.m., the Future room was inspected. The room is over 500 square feet and was filled with combustible storage making it a hazardous room. The north wall of the room was not finished to the roof deck or a drop-in ceiling. It was open to a large void space above the next room. The void space was about 8-9 feet high. The sprinkler coverage in the void space only dropped down into the next room through the drop in ceiling.

3. During an observation on 5/17/22 at 10:02 a.m., the boiler room was inspected. There were several unsealed penetrations around pipes and ducts in the room.

Based on observation, the facility failed to maintain the fire alarm control panel and all components in accordance with NFPA 72 National Fire Alarm Code, 2010 Edition, Section 10.5.5.2.1 and 10.5.5.2.2

Findings include:

1. During an observation on 5/17/2022 at 10:26 a.m., the panel and breaker supplying power to the FACP was not identified at the fire alarm control unit. The breaker at the panel must also be identified in red marking as "Fire alarm circuit."

Based on observation, the facility failed to

a) ensure the facility sprinkled throughout in accordance with NFPA 101 2012 Edition, Section 18.3.5.1 and 9.7,

b) ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Sections 8.6.5.2 and Table 8.6.5.1.2.

c) ensure concealed spaces open to hazardous rooms were properly sprinkler protected in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Sections 8.15.1.1, 8.15.1.2.1 8.6.5.2

d) maintain proper distances between sprinkler heads, in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.3.4.1.

Findings Include:

1. During an observation on 5/17/2022 at 9:50 a.m., the "future room 2122" was inspected. The room is over 500 square feet. It is being used as storage, and is considered a hazardous room. The north wall of the room is unfinished giving access to the very large void space over the rooms to the north. The void space has combustible material around ductwork, electrical, and fiberglass insulation covered with a vapor barrier on the roof deck. The future room has sprinkler protection up to within 12 inches of the ceiling, but the void space above the rooms to the north does not have any sprinkler protection up to within 12 inches of the ceiling.

2. During an observation on 5/17/2022 at 10:10 a.m., the "nothing room" outside the employee exit was inspected. The small room contained items stored in the room, the room did not have a sprinkler head.

3. During an observation on 5/17/2022 at 10:12 a.m., the employee exit vestibule was inspected. The sprinkler head in the vestibule was found to be blocked by a ceiling mounted heater. The heater was lower than the deflector of the sprinkler head.

4. During an observation on 5/17/2022 at 10:50 a.m., the administration suite was inspected in regards to the sprinkler heads. There were two heads in the hall which were less than 6 feet apart.

5. During an observation on 5/17/2022 at 11:29 a.m., the Public Health exam room was inspected. There were two heads in the hall which were less than 6 feet apart.

6. During an observation on 5/17/2022 at 11:45 a.m., the electrical closet 1329 was inspected. There was no sprinkler head in the room. There was no ceiling in the room. The room went as high as the roof deck above. There was no sprinkler coverage within 12 inches of the roof deck.

Based on observations, the facility failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).

Findings include:

1. During an observation on 5/17/2022 at 9:42 a.m., the IT room 2114 was inspected, there were ceiling tiles out of their place in the drop down ceiling in the room.

2. During an observation on 5/17/2022 at 11:16 a.m., the room labeled biohazard was inspected. There were ceiling tiles out in the room.

3. During an observation on 5/17/2022 at 11:17 a.m., the CT room was inspected. There were ceiling tiles out in the room through which a piece of equipment came through the ceiling. This area needs to be sealed up around the equipment.

Based on observation, the facility failed to properly mount a fire extinguisher in accordance with NFPA 10, 2010 Edition, Section 7.2.1.2.

Findings include:

1. During an observation on 5/17/2022 at 10:27 a.m., electrical room 1240 was inspected. The portable extinguisher in the room had not been initialed as having been inspected since January of 2022.

2. During an observation on 5/17/2022 at 11:01 a.m., the clean side of the laundry was inspected. The portable extinguisher in the room had not been initialed as having been inspected since March of 2022.

3. During an observation on 5/17/2022 at 11:03 a.m., the clean side of the laundry was inspected. The portable extinguisher in the room had not been initialed as having been inspected since February of 2022.

4. During an observation on 5/17/2022 at 11:19 a.m., the laboratory was inspected. The portable extinguisher in the room had not been initialed as having been inspected since February of 2022.

Based on observation, the facility failed to protect corridor openings by not ensuring all doors have proper maximum clearance to floor coverings in accordance with NFPA 101, 2012 Edition, Section 18.3.6.3.1.

Findings include:

1. During an observation on 5/17/2022 at 10:05 a.m., the corridor door to mechanical room 2126 was inspected. The gap at the bottom of the door was greater than 1 inch to the concrete floor.

Based on observations, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 5/17/2022 at 11:15 a.m., storage room 1117 was inspected. The electrical panels in the room were found to be blocked by a rolling can and other miscellaneous boxes.

Based on observation, the facility failed to ensure an emergency stop button for the generator was installed in accordance with NFPA 110, 2010 Edition, Section 5.6.5.6.

Findings include:

1. During an observation on 5/17/2022 at 9:00 a.m., the generator was inspected. The generator providing power for emergency power did not have a remote manual stop outside of the housing of the prime mover or elsewhere on the premises, even while being located outside.

Based on observation, the facility failed to maintain proper signage on the door of the oxygen storage room, in accordance with NFPA 99 Healthcare facilities code, Section 11.3.4.2.

Findings include:

1. During an observation on 5/17/2022 at 11:39 a.m., the oxygen storage area in the LTC was inspected. The room lacked the proper signage for oxygen storage.