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Based upon observation and staff interview, the facility fails to assure that proper delayed egress signage is posted as required. Failure to have the delayed egress signage posted could result in the door operator not completing the pressure requirement for the required time and not being able to exit the building during an emergency, affects some patients, visitors and staff in 1 of 8 smoke zones. Facility has a capacity of 49 with a census of 16 at the time of this survey.

Findings include:

During the survey conducted on 1/10/19 the following deficiency is noted:

1.)At 11:48 a.m., In the LDRP area there is no signage on the 15 second delayed egress doors on both unit exits.

Staff A was present and acknowledged the finding.

NFPA Standard: 101 2012 ed. 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (1) The door leaves shall unlock in the direction of egress upon actuation of one of the following: (a) Approved, supervised automatic sprinkler system in accordance with Section 9.7 (b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6 (c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6 (2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism. (3) *An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lb. (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. (4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS (5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9.

NFPA standard: 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1-1/2-hour duration is automatically provided in accordance with 7.9. The deficient practice could result in a failure to provide illumination in the event of a power failure, affecting all patients, visitors and staff in 8 of 8 smoke zones. The facility has a capacity of 49 and a census of 16 at the time of this survey.

Findings include:

During the record review of records on 1/9/2019, Between the hours of 12:30 P.M. and
4:30 P.M., the following is observed:

1.) No documentation of a 30-second functional within 24 hours, following the annual 90-minute testing of the emergency lighting units through the facility.

Staff A was present and acknowledged the finding.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2012 NFPA 101, 7.9.3

Based upon observation and staff interview, the facility fails to assure that cooking equipment is protected and maintained in a in accordance with the requirements of NFPA 10. The deficient practice increases the risk of an uncontrolled kitchen fire, affecting all patients, visitors and staff in 1 of 8 smoke zones. The facility has a capacity of 49 and a census of 16 at the time of this survey.

Findings include:

During the survey conducted on 1/10/19 the following deficiency is noted:

1.) At 10:04 a.m., the kitchen hood suppression system monthly check was not performed for the month of September 2018.

2.) At 10:20 a.m., the kitchen hood suppression system monthly checks were not performed since the last service in August 2018.

Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 10 5.5.5.3 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher.

Based upon observation and staff interview, the facility fails to assure that Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10. The deficient practice could result in the inability to reach a fire extinguisher and extinguish a fire, affecting some patients, visitors and staff in 1 of 8 smoke zones. The facility has a capacity of 49 with a census of 16 at the time of this survey.

Findings include:

During the survey conducted on 1/10/19 the following deficiency is noted:

1.) During the survey at 10:16 a.m. it is observed that the class K fire extinguisher is obstructed by a metal shelf.

Staff A was present and acknowledged the finding.

NFPA Standard: Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). 2010 NFPA 10 6.1.3.8

Based upon a review of records and staff interview, the facility fails to assure that all personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. The deficient practice could result in the mishandling of medical gases and cylinders, affecting all patients, visitors and staff in 8 of 8 smoke zones. The facility has a capacity of 49 with a census of 16 at the time of this survey.

Findings include:

During the record review of records on 1/9/2019, Between the hours of 12:30 P.M. and
4:30 P.M., the following is observed:

1.) No documented training and certification or credentialing of persons who handle medical gases and cylinders.

Staff A was present and acknowledged the finding.
NFPA Standard: Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.
11.5.2.1 (NFPA 99)

NFPA Standard: Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)