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Based on visual observation the facility failed to submit plans for construction in old MRI building that is currently under construction and fire walls are being built. No plans were submitted to the Office of State Fire Marshal for review. Code states Any building undergoing repair, renovation, modification, or reconstruction must comply with new and existing requirements.

Finding:
During the facility tour between the hours of 8:00am and 4:00pm, it was observed that construction has begun on what use to be the old MRI room. No plans have been submitted to OSFM for review as of yet.

Interview with maintenance director revealed he was unaware plans had to be submitted.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 62 of 62 residents.

Findings:

During the facility tour, between the hours of 8:00am and 4:00pm, it was observed that the sprinkler system is currently yellow tagged for several issues

Interview with maintenance director revealed the facility was aware of the deficiency and are in the process of trying to get the issue repaired.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier was filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 62 of 62 residents.
All smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 8:00am and 4:00pm it was observed that all smoke walls on all floors had penetrations that were not sealed properly.

Interview with maintenance director revealed the facility was not aware that the smoke barrier had penetrations that was not sealed

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 62 of 62 residents.
4 of 4 quarters were deficient.

Findings:

During the record review, between the hours of 8:00am and 4:00pm, it was observed that the alst fire drill was conducted 4/14/15. Only two fire drills were present in log and both were over a year ago. Some staff members on all floors did not know what to do during fire drill.

Interview with Maintenance Director revealed the facility was aware fire drills were not being held for (shift) and verified by the Administrator during the exit interview.

Based on visual observations the facility failed to maintain Gas and vacuum piped systems as per NFPA 99. During inspection of the maintenance test book it was observed that the company that inspected the medical gas systems,CHT World Class Healthcare Compliance, provided a report indicating several deficiencies. It is unknow if any deficiencies have been corrected.

Findings:

During facility tour between 8:00am and 4:00pm it was observed that the facility had several deficiencies cited on their last inspection report for medicla gas issues throughout facility.

Interview with maintenance director revealed he was unaware of the deficiencies that were found during last inspection.

Based on visual observation and record review, the facility failed to assure that the generator was supplied with a disconnected shut off switch
Findings:

During the record review, between the hours of 8:00am and 4:00pm it was observed that the generator did not have a shut off as required

Interview with maintenance director revealed the facility was aware that the generator shut off device was needed and they are in the process of getting one installed

Based on visual observation the facility failed to maintain no smoking or non-smoking signs in areas where oxygen is in use. Oxygen is flammable in nature and when bottles are placed to close to an ignition source it could result in a fire emergency. The deficient practice had the potential to affect 62 of 62 residents.

Findings:

During the facility tour, between the hours of 8:00am and 4:00pm it was observed that oxygen tanks were found stored in closets that were not makred for oxygen use. Several were stored in staorage closets with wheelchairs.

Interview with maintenance director revealed the facility was not aware that the oxygen tanks were not being stored properly