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Based upon observation, doors required to be self-closing are held open by nonapproved means. Failure to maintain the door in the closed position or employ an approved hold-open device can compromise the safety of the means of egress for which the door separation is intended in the event of a fire/smoke condition within the space.

Findings include:

On 02/21/2024 while in the company of the SO and MC it was observed that hazardous area egress doors are being held open by non compliant methods 7.2.1.8.2. The example locations:

A. At 11:10am door wedge used on Storage room across the corridor from Surgery Storage.

B. At 11:15am door wedge used for Compactor room

C. At 12:05pm door wedge used for door between Kitchen and Dining

D. At 12:09pm door tie back used for Dry Good Storage door.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition.

The finding is:

On 02/21/2024 at 10:15am while accompanied by the MC exit access was observed not to be identified by exit signage located to comply with 39.2.5.2 and 7.5. Location observed: Laundry room, exit discharge door lacks an exit sign. The exit sign is place above an overhead rolling door not used for exiting.

Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes safety of all building occupants.

The finding is:

On 02/21/2024 at 12:20pm pm in the company of the SO and MC the facility failed to indicate that the kitchen hood suppression system complies with NFPA 96, 2011, 10.4.1 and 10.4.3. There is a gas fuel shut off located near the floor between the wall and the gas appliance(s). There is a box end wrench hanging from the gas pipe. The surveyor was informed that the wrench is used to shut off the gas fuel. It could not be confirmed that the suppression system will automatically shut off the gas fuel or if it is manually shut off during an emergency.

Based on observation, not all portions of the building's fire alarm system are installed and maintained as required. This deficient practice could affect patients, staff, or visitors in the building because the fire alarm system could fail to activate under emergency conditions if the components are not properly installed and maintained.

The findings are:

A. On 02/21/2024 at 10:19am while accompanied by the MC, a fire alarm manual pull station was not provided within 5' of a designated exit. This condition does not comply with NFPA 72-2010, 17.14.6. Location observed: Laundry room exterior discharge door.

B. On 02/21/2024 at 11:09am while accompanied by the MC and SO, a fire alarm manual pull station is not visible. This condition does not comply with NFPA 72-2010, 17.14.6. Location observed: Kitchen exit door leading to Dining room contains a pull station hidden from observation by an Ice Tea Dispenser.

Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes safety of all building occupants.

The finding is:

On 02/21/2024 at 12:55pm in the company of the SO and MC during review of the Fire Alarm inspection documents the vendor indicated that two manual pull stations are no longer connected to the fire alarm system. This condition provides a false sense of safety to any individual during a fire emergency should they attempt to activate the fire alarm using the disconnected device. This condition does not comply with NFPA 72, 2010 10.17. The location of the two devices was not provided within the documentation.

Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes of all building occupants.

the finding is:

On 02/21/2024 at 12:45pm accompanied by the SO and MC, Documentation was not provided which indicates that a from the floor inspection is conducted annually for sprinkler heads to comply with NFPA 25, 2011, 5.2.1.1.

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

The finding is:

On 02/21/2024 at 11:20am while accompanied by the SO and MC a corridor door did not latch to a closed position which does not comply with 19.3.6.3. Location observed: Storage room across from Surgery Storage. This door lacks a usable strike for the door latch to engage. This door simply pushes open.

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

The finding is:

On 02/21/2024 at 12:25pm during document review with the SO and MC, Facility fire drill documentation for the past 12 months did not indicate that requirements comply with 19.7.1. and 4.7.2. There is no indication that fire alarm components/devices are utilized during a drill due to the following:
The Facility's Fire Drill forms do not indicate the use or acitvation of a fire alarm device during any drill.