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Based on observation and interview, the facility did not maintain doors to be self-closing doors or automatic closing devices complying with NFPA 101 - 2012 edition, Sections 18.2.2.2.7 and 7.2.1.8. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

On 08/29/2023 at 2:13 pm, observation at door HC1399B.1 revealed that the door is labeled as a 45-minute door but did not positively latch after 3 tries.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on observation and interview, the facility did not ensure that the stair shaft is maintained in accordance with NFPA 101 - 2012 edition, Sections 18.2.2.3 and 7.2.2.5.3. This deficient practice could affect 12 patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 08/29/2023 at 2:04 pm, observation in the lower landing of Stair - 1 revealed that it was being used to store two stacks of plastic chairs on chair dollies, and three carts under the stair.

2. On 08/29/2023 at 3:15 pm, observation of the 1st floor landing of Stair - 2 revealed that it contained a small waste basket with plastic liner sitting beside the exit door from the stairwell to the outside.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on record review and interview, the facility did not provide a complete policy addressing when the fire alarm system is out of service in accordance with the requirements of NFPA 101 - 2012 edition, 9.6.1.6 and Federal Register Vol. 81, No. 86, page 26886. This deficiency has the potential to affect all residents, and an undetermined number of staff and visitors.

Findings include:

On 08/29/2023 at 12:05 PM, record review revealed the "Fire Watch" policy for fire alarm impairment over 4 hours in any 24-hour period, did not specify that rounds or tours are to occur in a constant and circulating method throughout the area affected by the fire alarm outage. It stated rounds were to be each hour. The policy also incorrectly identified the State Agency it is to notify as the Bureau of Quality Assurance instead of the Department of Quality Assurance.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on record review and interview, the facility did not provide a complete policy addressing when the sprinkler system is out of service in accordance with the requirements of NFPA 101 - 2012 edition, 9.7.5, NFPA 25, 2011 edition, 15.5.2(4) and Federal Register Vol. 81, No. 86, page 26886. This deficiency has the potential to affect all residents, and an undetermined number of staff and visitors.

Findings include:

On 08/29/2023 at 12:05 PM, record review revealed the "Fire Watch" policy for fire sprinkler impairment over 10 hours in any 24-hour period, did not specify that rounds or tours are to occur in a constant and circulating method throughout the area affected by the sprinkler system outage. It stated rounds were to be each hour. The policy also incorrectly identified the State Agency it is to notify as the Bureau of Quality Assurance instead of the Department of Quality Assurance.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on observation and interview, the facility did not maintain portable fire extinguishers as required by NFPA 101 - 2012 edition, Sections 18.3.5.12 and 9.7.4.1, as well as NFPA 10, 2010 edition, Sections 6.1.3.1 and 7.2.2. This deficient practice has the potential to affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 08/29/2023 at 1:41 pm, observation in the kitchen revealed that access to the portable fire extinguisher was obstructed by a rolling cart placed in front of the fire extinguisher.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on observation and staff interview, the facility did not maintain corridor doors in accordance with NFPA 101 - 2012 edition, Section 18.3.6.3.5 and 7.2.1.5.10.2. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

On 08/29/2023 at 2:34 pm, observation of corridor double door HTC2105 revealed that it contained a manual flush bolt at the top edge of the inactive leaf. The bolt was operational as a dead-bolt only and was not positive latching.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on observation and interview, the facility did not maintain smoke barriers in accordance with the requirements of NFPA 101 - 2012 edition, Sections 18.3.7.3, 8.5.2 and 8.5.6. This deficient practice could 12 patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 08/29/2023 at 2:38 pm, observation above the ceiling at the corridor double acting door HTC2100.1 revealed that there was one (1) 3-inch sleeve that was not sealed with a listed system for smoke barrier walls.

2. On 08/29/2023 at 2:44 pm, observation above the ceiling in corridor HTC2099B revealed a 1-inch metal sleeve penetrating the smoke barrier wall. It was not sealed with a listed penetration system.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff A.

Based on observation and interview, the facility did not maintain the HVAC system filtration in accordance with the requirements of NFPA 101 - 2012 edition, Sections 18.5.1, 18.5.2 and 9.2, NFPA 99 - 2012 edition, Section 9.3.1.1 and ASHRAE 170 - 2008 Table 6-1. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 08/29/2023 at various times during the inspection, observation of air flows at the temporary main entrance, clinic entrance, emergency exit from the dining area, exit at receiving, exit from medical gas room, and doors into the ambulance bay all exhibited air flow into the hospital. The flow through the doorways was from very noticeable at the main entrance to easily detectable at the ambulance bay. This air is not being filtered as required. Staff said they have notified the mechanical installers and the system has been worked on a few times over the past weeks to solve this problem.

This deficient condition was confirmed at the exit conference with interviews with Staff A, Staff D, Staff E, and Staff L.

Based on record review and interview the facility did not have a written fire safety plan that addressed the items required by NFPA 101 - 2012 edition, Section 18.7.2.2(3). This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 08/29/2023 at 12:07 PM, review of the document titled "Fire Response Plan, New Facility" revealed that the facility's written fire safety plan did not address an emergency phone call to the fire department by staff.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff A.

Based on observation and interview, the facility failed to maintain a clear working space in front of one electrical panel in accordance with NFPA 101 - 2012 edition, Section 9.1.2 and NFPA 70, 2011 edition, Section 110.26. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

On 08/29/2023 at 2:50 pm, observation in OR2 revealed that access to the electrical panel was less than the minimum required 3'-0" clearance. The panel was being blocked by a procedure cart.

This deficient practice was confirmed at the time of discovery by a concurrent interview with OR Staff.

Based on observation and interview, the facility did not store oxygen cylinders in accordance with the requirements of NFPA 101 - 2012 edition, Sections 18.3.2.4, as well as NFPA 99, 2012 edition, Sections 11.3.2, 11.3.2.1 and 11.3.4. These deficient practices could affect an undetermined number of staff and visitors.

Findings include:

1. On 08/29/2023 at 1:57 pm, observation in Medical Gas HTC1803 revealed that combustible vinyl base was used on the walls. The room contains more than 300 cubic feet and less than 3000 cubic feet of nonflammable gases.

2. On 08/29/2023 at 2:58 pm, observation in Storage HTC2228 revealed that a No-Smoking precautionary sign was not displayed on the door. There were 40 E-size oxygen bottles in racks that were segregated between full and empty. The room also included combustible vinyl flooring and base along with combustible storage within 5 feet of the bottles. The room contains more than 300 cubic feet and less than 3000 cubic feet of nonflammable gases.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff A.