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Based on record review the facility failed to plan and implement a provision of subsistence needs for the staff and the residents. This affects all occupants in the facility.

Findings include:

1. Review of the EP plan, policies, and procedures on 5/18/2022, reflected the facility's emergency plan lacked policies and procedures for subsistence needs for staff and residents, particularly specific policies describing alternate sources of energy to maintain proper temperatures, emergency lighting, and for the sprinkler and alarm systems.

Based on observation, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5., 10.2.

Findings include:

1. During an observation on 05/18/22 at 11:13 a.m., the director of nursing office was inspected. The corridor door was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

2. During an observation on 05/18/22 at 11:15 a.m., the LTC bathing room was inspected. The corridor door was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people

Based on observation, the facility failed to assure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 5/18/2022 at 11:12 a.m., the biohazard storage room was inspected. The room was being used as a storage area, it is over 50 square feet. There was no self-closing device on the corridor door as required for storage rooms.

2. During an observation on 5/18/22 at 12:25 p.m., the med records storage room was inspected. The door was exercised two times and both times failed to latch under the power of the self-closer.

Based on observation, the facility failed to

a) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3)

b)ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.

Findings include:

1. During an observation on 5/18/2022 at 11:00 a.m., the kitchen janitor's closet was inspected. The sprinkler head in the room was missing the escutcheon ring.

2. During an observation on 5/18/2022 at 11:28 a.m., room B-10 was inspected. The sprinkler head in the room was missing the escutcheon ring.

3. During an observation on 5/18/2022 at 11:50 a.m., hospital room 6 was inspected. The sprinkler head in the room was missing the escutcheon ring.

4. During an observation on 5/18/2022 at 11:55 a.m., the standpipe room was inspected. There was an electrical conduit suspended from the sprinkler main pipe in the room.

5. During an observation on 5/18/2022 at 12:05 p.m., the laundry was inspected. There were water lines zip-tied to the sprinkler pipes in the room.

Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1. The deficiency could affect 1 of 1 basement smoke compartment.

Findings include:

1. During an observation on 5/18/2022 at 11:34 a.m., the portable extinguisher in the C-hall was found to be mounted at 64" high, 4 inches higher than the maximum height of 60".

Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 19.3.7.8.

Findings include:

1. During an observation on 5/18/2022 at 11:20 a.m., the B-hall cross-corridor smoke/fire doors were inspected. The left leaf of the doors was found to be heavily rubbing on the upper frame, it was sticking upon opening the door.

Based on record review, the facility failed to maintain a full and complete fire plan in accordance with NFPA 101, 2012 Edition, Section 19.7.2.2.

Findings include:

1. A review of the facility fire plan and fire drill records reflected a lack of direction and training for staff to call 911 directly, even though the facility has a dialer and monitoring agency. The fire drill evaluation sheets also lacked any documentation that the hallways were being cleared of all wheeled medical equipment.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). This deficiency affects all of the fire/smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 5/18/2022, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors as well as doors with special locking arrangement in the building (if applicable) and show inspections of all components of the doors in those barriers. The inspection documentation must include all the components in NFPA 80-2010 Section 5.2.

Based on observation, the facility failed to ensure an emergency stop button for the generator was installed in accordance with NFPA 110, 2010 Edition, Section 5.6.5.6.

Findings include:

1. During an observation on 5/18/2022 at 12:20 p.m., the generator was inspected. The generator providing power for emergency power did not have a remote manual stop outside of the housing of the prime mover or elsewhere on the premises, even while being located outside.