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Based on observation and interview, the facility failed to maintain means of egress free and clear of obstructions in 1 of 5 smoke compartments (200 Hall). This deficient practice could delay evacuation of 2 residents in the event of an emergency. The facility census was 4.

Findings are:

Observation on 7-14-2020 at 11:03 AM revealed the following:

1) Facility allowed a coffee table to be placed within the 200 Hall exiting corridor path of travel reducing the corridor width.

During an interview on 7-14-2020 at 11:03 AM, Maintenance Staff confirmed the finding.

Based on observation and staff interview, the facility failed to ensure all hazardous areas were separated by smoke resistant partitions in 3 of 5 smoke compartments (200 Hall, ER/Lab/Surgery, and Administrative/Kitchen). This condition would allow smoke to migrate into the exit corridor, which would affect 2 residents. The facility census was 4.

Findings are:

Observations on 7-14-2020 between 10:43 AM and 11:21 AM revealed the following:

1) The kitchen storage room door was held open by a door wedge on the floor.
2) The kitchen janitor closet door was held open by a door wedge on the floor.
3) The storage room by OB Room 1 door did not latch within the doorframe due to the latch being taped closed.
4) Resident Room #205 being used as a storage room did not have a self-closing door at the corridor.
5) The janitor/housekeeping closet by the nurse station had multiple unsealed pipe and conduit penetrations with gaps greater than 1-inch.
6) The MRI mechanical room had multiple unsealed pipe and conduit penetrations with gaps greater than 1-inch.

During interviews on 7-14-2020 between 10:43 AM and 11:21 AM, Maintenance Staff confirmed the finding.

Based on observation and staff interview, the facility failed to provide a ceiling meeting a Class A or Class B flame/smoke spread rating in 1 of 5 smoke compartments (ER/Lab/Surgery). This deficient practice did not ensure smoke and gasses would be kept below the ceiling to activate the fire sprinkler system and or the fire alarm system and would cause these system to fail to operate as designed and would affect 0 residents. The facility census was 4.

Findings are:

Observations on 7-14-2020 at 11:28 AM revealed the following:

1) Facility failed to maintain the drop-tile ceiling in the ER/Lab/Surgery smoke compartment by allowing a ceiling tile to be missing in the Lab Draw Room area near the south door.

During an interview on 7-14-2020 at 11:28 AM, Maintenance Staff confirmed the finding.

Based on observation and interview, the facility failed to maintain the minimum required clearance for fire sprinklers in 1 of 5 smoke compartments (ER/Lab/Surgery). The deficient practice would cause an obstruction to the water spray in the event of a fire, and failure of fire sprinklers to operate as designed. The deficient practice would affect 0 residents. The facility census was 4.

Findings are:

Observations on 7-14-2020 at 11:27 AM revealed the following:

1) The facility failed to maintain a minimum of 18-inches of clearance from the fire sprinkler deflector in the Lab Storage Room due to obstructions on the top shelf.

During an interview on 7-14-2020 at 11:27 AM, Maintenance Staff confirmed the finding.

Based on documentation review and interview, the facility failed to ensure that the transfer time from normal power to emergency power was not more than 10 seconds. This deficient practice increased the potential that the generator would fail to run during loss of power, which would affect all building occupants in 5 of 5 smoke compartments. The facility census was 4.

Findings are:

Record review on 7-15-2020 at 5:20 PM revealed the following:

1) Facility failed to document the generator transfer time on the inspection log.

During an interview on 7-15-2020 at 5:36 PM, Maintenance Staff confirmed the finding.

Based on observation and interview, the facility allowed the use of extension cords in lieu of permanent wiring. This deficient practice increased the potential for an electrical fire in 1 of 5 smoke compartments (ER/Lab/Surgery) and would affect 0 residents. The facility census was 4.

Findings are:

Observation on 7-14-2020 at 11:18 AM revealed the following:

1) The Surgery Boiler Room had an air compressor and a soap dispenser plugged into a yellow 3-way electric extension cord.
During an interview on 7-14-2020 at 11:18 AM, Maintenance Staff confirmed the finding.