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Based on observation, the facility failed to provide provisions for the rapid removal of occupants by the full-time magnetic locks on the egress doors per the requirements of:

2012 NFPA 101, 19.2.2.2.5.1, and 19.2.2.2.6

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 01/11/2022, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed the facility had installed toggle switches in the 8'-0" ceiling at each door and at the Nurses' Station to unlocked the full time magnetic locked doors in case of an emergency. The switches were not readily accessible for all staff.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 21.9, and 14.4.5.3.2

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 01/11/2022, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed the following :
1. All exterior full time magnectic locked egress doors failed to automatically unlock upon loss of power to the fire alarm system, these doors did release under key pad, and activation of the fire alarm system.
2. The facility failed to provide documentation of conducting a Smoke Detector Sensitivity Test within the past 2 years.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to maintain the corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.10
42 CFR 482.41 (b) (1)
S&C-07-18

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 01/11/2022, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed the following:
1. A rubber wedge was found holding the DON's corridor door open.
2. Resident's room 216 had a gap of 3/4 inch between the door and door frame when the door was closed and latched.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to maintain the electrical wiring and equipment per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.2
2011 NFPA 70, 110.26

This deficiency affects 1of 2 smoke compartments.

Findings include:

On 01/11/2022, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed a treadmill and other exersice equipment blocking the designated work space for the electrical panels located in the partial basement.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 01/11/2022, during a tour of the facility from 10:30 am to 4:30 pm, the surveyor observed a portable space heating device that was plugged in, but not on and was located in the Doctors Lounge and the facility was unable to provide documentation that the heating element did not exceeding 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.