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Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8.

Findings include:

1. During an observation on 2/6/24 at 10:26 a.m., the corridor from the kitchen to the back receiving area was inspected. The door separating receiving from the kitchen was being held open by the arm of an electric wheelchair.

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.

This deficiency affects all smoke compartments.

Findings include:

1. During an observation on 2/6/24 at 10:29 a.m., the fire alarm control panel (FACP) was inspected. The main power circuit panel and breaker was not identified at the FACP. There were two electrical panels which held breakers for the FACP. The correct breaker was also not identified at the panels.

Based on an observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7

Findings include:

1. During an observation on 2/6/24 at 10:20 a.m., the cafeteria was inspected. A fire alarm pull station was blocked by a table with a microwave sitting on it.

Based on observation, the facility failed to sprinkle the receiving area under the overhead door, in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.1 and NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.7.5.3.2.

Findings include:

1. During an observation on 2/6/24 at 10:27 a.m., the receiving area was inspected. There was no sprinkler coverage under the overhead door when it was in the open position.

Based on observation, the facility 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 2/6/24 at 11:00 a.m., the portable extinguisher in the area of the standpipe was inspected. It was not marked as having been inspected in January.

Based on record review, the facility failed to ensure piped oxygen shutoff valves were accessible in accordance with NFPA 99 Healthcare Facilities Code 2012 Edition, Section 5.1.4.8.4.

Findings include:

1. During an observation on 2/6/24 at 11:10 a.m., the zone valve boxes were identified. The zone valve box for rooms 4-10 and the lab was found to have a large desk, a chair, and a computer cart set up for the CNAs, in front of the zone valves. Zone valves must remain clear of obstruction at all times.