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Based on observation and staff interview, the facility failed to maintain means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain means of egress as required could delay egress resulting in injury or death during an emergency. The deficiencies affected one (1) of numerous exits. The findings were:

Observation on 12/17/2019 at 9:04 AM at the facility exit adjacent to the environmental services (EVS) closet revealed the exit fully blocked by cleaning equipment.

Interview with the facility maintenance director at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 39.2.1.1; 7.1.10.1
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Based on document review and staff interview the facility failed to maintain fire alarm systems in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to maintain fire alarm systems as required could result in injury or death during an emergency. The deficiency affected 1 of 3 (alarm initiating, supervisory alarm initiating, and notification) testing requirements of the fire alarm system. The findings were:

Document review on 12/17/2019 at 11:30 AM revealed the facility could not verify that each horn and strobe notification device had passed visual and audible inspection on an annual basis.

Interview with the facility maintenance director at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.3.4.1; 9.6.1.5
2010 NFPA 72, Sections: 14.4.5(20); 14.6.2.4; Figure 14.6.2.4 page 11
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Based on observation and staff interview, the facility failed to maintain portable fire extinguishers in accordance with the 2012 NFPA 101, Life Safety Code and the 2010 NFPA 10, Standard for Portable Fire Extinguishers. Failure to maintain portable fire extinguishers as required could result in injury or death during an emergency. The deficiency affected three (3) of three (3) portable fire extinguishers. The findings were:

Observation on 12/17/19 at 2:30 PM in the main hallway revealed a portable fire extinguisher that had not been inspected and signed off for the month of November 2019. Further observation revealed two (2) additional portable fire extinguishers that had not been inspected and signed off in November 2019, and were blocked by medical equipment.

Interview with the facility maintenance director acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 39.3.5, 9.7.4.1
2010 NFPA 10, Sections: 7.2.1.2; 7.2.4.3; 7.2.2(2)

Based on observation and staff interview, the facility failed to maintain portable fire extinguishers in accordance with the 2012 NFPA 101, Life Safety Code and the 2010 NFPA 10, Standard for Portable Fire Extinguishers. Failure to maintain portable fire extinguishers as required could result in injury or death during an emergency. The deficiency affected one (1) of numerous fire extinguishers. The findings were:

Observation on 12/17/2019 at 8:35 AM in the northwest hallway revealed a portable fire extinguisher obstructed by a portable X-ray machine.

Interview with the facility maintenance director at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 39.3.5; 9.7.4.1
2010 NFPA 10, Section: 7.2.2(2)
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Based on observation and staff interview, the facility failed to maintain portable fire extinguishers in accordance with the 2012 NFPA 101, Life Safety Code and the 2010 NFPA 10, Standard for Portable Fire Extinguishers. Failure to maintain portable fire extinguishers as required could result in injury or death during an emergency. The deficiency affected three (3) of three (3) portable fire extinguishers. The findings were:

Observation on 12/17/19 at 3:00 PM in the main hallway revealed a portable fire extinguisher that had not been inspected and signed off for the month of November 2019. Further observation revealed two (2) additional portable fire extinguishers that had not been inspected and signed off in November 2019.

Interview with the facility maintenance director acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 39.3.5, 9.7.4.1
2010 NFPA 10, Sections: 7.2.1.2; 7.2.4.3

Based on observation and staff interview, the facility failed to maintain electrical systems in accordance with the 2012 NFPA 101, Life Safety Code and the 2011 National Electrical Code. Failure to maintain electrical systems as required could cause a fire resulting in injury or death. The deficiencies affected one (1) of numerous rooms in the facility. The findings were:

Observation on 12/17/2019 at 9:04 AM in the environmental services (EVS) closet revealed equipment stored in front of electrical panels. Further observation revealed the equipment within three (3) feet of the electrical panels.

Interview with the facility maintenance director at the time of observation acknowledged the equipment, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 9.1.2
2011 NFPA 70, Section: 110-26

Based on document review and staff interview, the facility failed to maintain HVAC systems in accordance with the 2012 NFPA 101, Life Safety Code and the 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. Failure to provide HVAC systems as required could result in fire and smoke spread resulting in injury or death. The deficiency affected one (1) of numerous testing requirements. The findings were:

Document review on 12/17/2019 at 11:30 AM revealed the facility could not verify that the fire dampers had been tested during the previous 72 months.

Interview with the facility maintenance director at the time of observation acknowledged the deficiency, and indicated he was unaware of the six (6) year requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.5.2.1, 9.2.1
2010 NFPA 80, Section: 19.4.1.1
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Based on observation and staff interview, the facility failed to maintain smoking regulations in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain smoking regulations as required could result in injury or death during an emergency. The deficiency affected one (1) of numerous entrances to the facility. The findings were:

Observation on 12/17/2019 at 10:30 AM at the surgery entrance revealed that the facility did not post a No Smoking sign despite being a no smoking facility. No Smoking signs need to be posted at all main entrances to the facility to ensure resident safety.

Interview with the facility maintenance director at the time of observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 19.7.4(2)
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Based on observation and staff interview, the facility failed to maintain electrical systems in accordance with the 2012 NFPA 101, Life Safety Code and the 2011 NFPA 70, National Electrical Code. Failure to maintain electrical systems as required could cause a fire resulting in injury or death. The deficiency affected one (1) of numerous rooms in the facility. The findings were:

Observation on 12/17/2019 at 9:18 AM in the pharmacy revealed a power strip plugged into another power strip creating a daisy chain.

Interview with the facility maintenance director at the time of observation acknowledged the daisy chain, and indicated awareness of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.5.1.1; 9.1.2
2011 NFPA 70, Section: 400-8