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Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3, 7.2.1.5.10, and 7.2.1.6. Facilities can only lock doors and gates in the case of clinical need such as a special care unit.

Findings include:

1. During an observation on 1/24/24 at 10:25 a.m., the doors leaving the recovery area were found to be maglocked, with an electronic opening push-button device marked with the universal "handicapped" symbol on the button. Entry to the recovery area was with an electronic device using a card to unlock the doors and enter. The system is set up as an "access-controlled" egress special locking arrangement. The motion detector was not a part of the system.

Whatever type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress, the facility must then apply all the features the code requires in NFPA 101-2012 Section 7.2.1.6. The locked doors in the lighted path of egress must also unlock and be open to occupants in the event the sprinkler or fire detection systems are activated.

2. During an observation on 1/24/24 at 10:50 a.m., the back corridor to surgery had marked exit signs leading to magnetically locked doors. This was set up as an "access-controlled" egress special locking arrangement. The motion detector was not a part of the system.

Based on observation, the facility failed to assure that all exit discharges were provided with a hard surface path to the public way. Per NFPA 101, 2012 Edition, Sections 39.2.1.1, 7.1.6.2, and 7.7.1.

The findings include:

1. The marked exit discharge from the dietary patio exit was examined on 1/24/24 at 9:45 a.m. The discharge ended on the patio with only a narrow gravel pathway to the the public way.

2. During an observation on 1/24/24 at 9:58 a.m., the north exit sidewalk out of the clinic was inspected. It was found to have ice and snow on the sidewalk going to the public way.

Based on observation, the facility failed to maintain continuous illumination for all exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1, failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.10.1.2.2., and failed to ensure a photo-luminescent sign was installed in accordance with NFPA 101 2012 Edition, Section 7.10.7.2.

Findings include:

1. During an observation on 1/24/24 at 10:02 a.m., the clinic hall coming from the north exit was inspected. There was an exit sign in the corridor which was found to not be illuminated. It was discovered there was a paper sign inside the light which was blocking the illumination.

2. During an observation on 1/24/24 at 10:10 a.m., the exit signage in the hospital was inspected. There was no visible exit signage guiding occupants to the exits when standing near the nurses station. There was an exit sign hidden by the architecture of the area guiding occupants toward the main entrance, but it was not visible from most of the area.

3. During an observation on 1/24/24 at 10:10 a.m., there was a photo-luminescent exit sign at the end of the corridor near room 12. There was no continuous illumination of the face of the sign by a reliable light source to ensure "charging" of the sign in case of a power outage or an emergency.

Based on observation, the facility failed to ensure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 1/24/24 at 10:12 a.m., resident room 12 was inspected. The room was being used for storage for extra beds, 4 in total. There was no self-closing device on the door.

Based record review, the facility failed to maintain the wet chemical extinguishing system for the kitchen hood in accordance with NFPA 17A, 2009 Edition, Section 7.5.1.

Findings include:

1. Review of the maintenance records on 1/24/24 showed the last hydro test on the main cylinder for the kitchen hood was completed in 2011 and was due in 2023.

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 1/24/24 at 10:12 a.m., resident room 12 was inspected. There was an ABHR station mounted over the light switch in the room.

Based on record review and observation, the facility failed to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 14.2, failed to 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, and failed to continuously maintain the sprinkler systems per NFPA 13-2010, Section 6.7.4.

Findings include:

1. During a review of facility records on 1/24/24, it was found that the 5 year internal pipe inspection for the sprinkler system had not been completed on time. The last time the internal inspection had been completed was 2017.

2. During a review of facility sprinkler maintenance records it was found the facility was not documenting monthly gauge pressure readings on the wet sprinkler side, and weekly dry side pressure readings.

3. During an observation on 1/24/24 at 10:39 a.m., the drain, and test connections and valves were not identified and permanently marked with waterproof metal or rigid plastic signs at the wet and dry risers.

Based on observation, the facility failed to ensure the installation of a direct vent fireplace met all regulatory criteria in accordance with NFPA 101 2012 Edition, Section 39.5.1, 39.5.2, 9.1, 9.2.2, and 9.8.

Findings include:

1. During an observation on 1/24/24 at 10:07 a.m., the main entrance lobby was inspected. There was a direct vent gas fireplace installed in the room. There was no electronically supervised carbon monoxide detector installed in the room.

Based on record review, the facility failed to ensure the fire safety plan and subsequent drills documented all requirements listed in the the code for responding to a fire drill per NFPA 101. 2012 Edition, section 19.7.1.2.

Findings include:

1. Review of the facility fire drills going back a year reflected the facility lacked documentation in regards to all the elements required by code for the fire safety plan, specifically, the facility was not training staff to make a simulated emergency call to the fire department or 911. Even the system dialer will alert the monitoring agency, the code requires staff to still call 911 and report about the alarm.

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 1/24/24., 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 interview, and record review the facility failed to inspect, test and document the testing and inspection of fusible link dampers in accordance with NFPA 80, Standard for Fire Door and Other Opening Protectives, 2010 Edition, Section 19.4.1.1.

Findings include:

During a review of facility records on 1/24/24, the fusible link dampers in the facility had not been exercised in the last six years, as there was no documentation to show they had.

In an interview on 1/24/24 at 8:00 a.m., staff member B stated they had not been exercised.

Based on observation the facility failed to maintain gas cylinders per NFPA 99-2012, Section 11.6.2.3.

Findings Include:

1. During an observation on 1/24/24 at 9:48 a.m., the administration area was inspected. There was a K-sized tank of helium free-standing on the floor within an office.