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Based on observation and interview, the facility failed to properly store liquefied petroleum in accordance with NFPA (National Fire Protection Association) 58, Liquefied Petroleum Gas Code (Section-8.3.1), 2008 Edition. This deficient practice affects approximately 3 staff in 1 of 3 smoke zones. This facility has a capacity of 16 and a census of 2.
Findings include:
Observation and interview on 10/04/22 at 8:53 a.m., revealed a 20 pound LP gas cylinder attached to a gas grill being stored in Boiler/Mechanical Room #206. The Plant Services Lead and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to install battery powered lighting in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.3.2.2.11.1), 2012 Edition. This deficient practice affects all patients receiving deep sedation and general anesthesia. This facility has a capacity of 16 and a census of 2.
Findings include:
Observation and interview on 10/04/22 at 9:38 a.m., revealed that Operating Room #511 and Endoscopy Room #507 did not contain battery powered lighting units. The battery powered lighting units are required in the event that there was a loss of power and the emergency generator should happen to fail. The Plant Services Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.2), 2012 Edition. This deficient practice affects approximately 5 residents, staff, and visitors in 1 of 3 smoke zones. This facility has a capacity of 16 and a census of 2.

Findings include:

Observation and interview on 10/04/22 at 9:00 a.m., revealed the Oxygen Storage Room contained an approximately 1/4 inch gap around an approximate 3/4 inch conduit that penetrated the east wall. Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure that corridor doors have a means of keeping the doors closed within the doorframe in order to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.5), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 1 of 3 smoke zones. This facility has a capacity of 16 and a census of 2.

Findings include:

Observation and interview on 10/04/22 at 9:20 a.m., revealed the panic hardware for the west corridor door to the Cafeteria had been disabled. By disabling the hardware this prevented the door from latching within the door frame in order to keep the door closed. The Plant Services Lead and Maintenance Staff verified this observation at the time of the survey process.

Based on observation, interview, and testing, the facility failed to maintain smoke barrier doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.7.8(1), 2012 Edition. This deficient practice affects approximately 10 residents, staff, and visitors in 2 of 3 smoke zones. This facility has a capacity of 16 and a census of 2.

Findings include:

Observation, interview, and testing on 10/04/22 at 9:07 a.m., revealed the south leaf of the cross corridor double smoke barrier doors in the PT Hall failed to fully self-close in order to resist the passage of smoke from one compartment to another. Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain electrical junction boxes in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code, 2011 Edition. This deficient practice affects approximately 2 staff and visitors in 1 of 3 smoke zones. This facility has a capacity of 16 and a census of 2.

Findings include:

Observation and interview on 10/04/22 at 9:12 a.m., revealed an open junction box with exposed electrical wiring located along the ceiling of the Respiratory Room. Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect fire door assemblies in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-5.2.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 16 and a census of 2.

Findings include:

Record review and interview on 10/04/22 at 9:53 a.m., revealed the facility was past due for annual inspection of the fire rated door assemblies throughout the facility. Documentation provided indicates the last inspection was conducted on 09/25/21. The Plant Services Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that power strips are being used in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-10.2.3.6), 2012 Edition. This deficient practice affects approximately 3 staff in 1 of 3 smoke zones. This facility has a capacity of 16 and a census of 2.

Findings include:

1. Observation and interview on 10/04/22 at 9:27 a.m., revealed a power strip being used to supply power to a fan in Office #128.

2. Observation and interview on 10/04/22 at 9:30 a.m., revealed a power strip being used to supply power to a fan in Office #120.

3. Observation and interview on 10/04/22 at 9:32 a.m., revealed a power strip being used to supply power to a refrigerator in Office #116. Maintenance Staff verified these observations at the time of the survey process.