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Based on observation, the facility failed to enclose an exit stairway marked as an exit from the basement per NFPA 101, 2012 Edition, Sections 19.3.1, and 8.6.2.

Findings include:

1. During an observation on 8/22/23 at 12:30 p.m., the interior stairwell on the hospital side, which comes out in the basement across from the elevator was inspected. It was discovered to be lacking a door at the bottom. Vertical openings such as stairwells, must be enclosed by 1 hour construction.

2. During an observation on 8/22/23 at 12:45 p.m., the interior stairwell on the long term care side, was inspected. It was discovered to be lacking a door at the bottom. Vertical openings such as stairwells, must be enclosed by 1 hour construction.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 8/22/23 at 11:48 a.m., the ER was inspected. There was an ABHR dispenser mounted over the helipad light switch in the area.

2. During an observation on 8/22/23 at 12:56 p.m., the PT room was inspected. There were 2 ABHR stations mounted over light switches at each end of the room.

Based on observations, the facility failed to maintain all fire alarm systems in accordance with the standards of NFPA 72-2010, Section 10.5.5.2.1 - 10.5.5.2.4.

Findings include:

1. During an observation on 8/22/23 at 12:03 p.m., the fire alarm control panel (FACP) was inspected. The main power circuit panel and breaker was not correctly identified at the panel. It appeared the panel cover had been turned upside down at some point, causing the wrong breaker to be identified as the breaker for the FACP.

Based on record review, the facility failed to ensure all smoke detectors had been tested for sensitivity in accordance with NFPA 72 National Fire Alarm and Signaling Code, 2010 Edition, Section 14.4.5.3.

Findings include:

1 .During record review on 8/22/2023, records for the fire alarm and smoke detection systems were requested. There was no documentation showing the smoke detector sensitivities had been completed within the last two years.

Based on observation the facility failed to maintain the sprinkler system by installing sprinkler heads too close to walls in accordance with NFPA 13 Standard for Automatic Sprinkler Systems, 2010 Edition, Section 8.5.5.2.2

Findings Include:

1. During an observation on 8/22/23 at 11:53 a.m., the soiled utility room by the clinic was inspected. There was a straight pendant sprinkler head within 2.5" of a cabinet mounted on the wall. The minimum distance a sprinkler head can be from the wall without being a directional head is 4".

Based on observation, the facility failed to:

a) maintain the monthly gauge readings on all of the sprinkler risers per NFPA 25-2011, Sections 5.2.4.1 and 5.2.4.2;
b)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. Review of inspection reports for the facility's wet sprinkler system on 08/22/2023, showed the facility lacked documentation of the monthly (wet) and weekly (dry) pressure gauge readings for the facilities sprinkler system.

2. During an observation on 8/22/23 at 12:35 p.m., the sleep room was inspected. There were missing ceiling tiles where dampers were located in the room in two places.

3. During an observation on 8/22/23 at 12:43 p.m., the payroll storage room was inspected. There was a ceiling tile out in the room.

Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1, and failed to inspect portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2.

Findings include:

1. During an observation on 8/22/23 at 12:48 p.m., the portable extinguisher in the basement, near central storage, was mounted 65 inches high, about 5 inches higher than the maiximum of 60 inches to the top of the handle of the extinguisher.

2. During an observation on 8/22/23 at 12:57 p.m., the portable extinguisher in the maintenance shop was found to be mounted 75" high on the wall near the door.

3. During an observation on 8/22/23 at 12:59 p.m., the portable extinguishers in the generator room and the transfer switch room were not inspected in July of 2023.

Based on observation, the facility failed to maintain corridor door openings in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.10.

Findings include:

1. During an observation on 8/22/23 at 12:20 p.m., room 112 was inspected. The room was a resident room and it was found with a chock block holding the corridor door open.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6 and 19.7.2.2.

Findings include:

1. During a review of facility fire drills on 8/22/2023, it was determined the facility had not completed a fire drill for the day shift and the night shift of the third quarter of 2022. Fire drills must be completed during the established shift hours.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

Findings include:

1. Review of the fire safety maintenance records on 8/22/2023, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

Based on record review, the facility failed to maintain the receptacles in patient areas.

Findings include:

Record review on 8/22/2023 revealed non-hospital grade receptacles located in resident care rooms throughout the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
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.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation, the facility failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1.

Findings include:

1. During an observation on 8/22/23 at 1:00 p.m., the generator was inspected. The generator lacked a labeled manual stop station at a remote location on the outside of the room housing the generator, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.