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Based on observation and interview, the facility failed to provide means of egress with sufficient headroom in accordance with the requirements of NFPA 101 (2012 edition), 7.1.5. This deficient practice could affect an undetermined number of out-patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

On 09/28/2022 at 9:38 am, it was observed that the headroom, in the exit stairwell (near the Boiler room), was less than the 6'-8" minimum from a plane parallel and tangent to the foremost portion of the stair tread measured vertically to the ceiling surface.

This finding was confirmed at the time of discovery by a concurrent interview with Staff C, Staff F, and staff V.

Based on record review and staff interview, the facility did not ensure that functional tests of the battery powered emergency illumination equipment was provided in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.2.9.1 and 7.9.3. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 09/27/2022 at 12:32 pm, review of the records for emergency lighting revealed that the facility could not provide documentation to verify that the battery-powered emergency lights were functionally tested on a monthly nor annual basis.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff C, Staff F and Staff V.

Based on observation and interview, the facility failed to provide an automatic sprinkler system in accordance with 2012 NFPA 101 s.19.3.5, 9.7 and 2010 NFPA 13 s.6.2.9. This deficient practice could affect all patients and an undetermined number of staff and visitors.

Findings include:

On 09/28/2022 at 9:12 am, observation at the sprinkler riser room revealed that there were not the minimum of six spare sprinkler heads nor 2 heads of each type sprinkler used in the facility. There was no list of the sprinkler heads used.

This deficient practice was confirmed by a concurrent interview with Staff C, Staff F and Staff V.

Based on observation, record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5.1 & 9.7.5; NFPA 25 (2011 edition) Sections 4.3, 5.1.1.2, 5.3.1.1.1.6. This deficient practice could affect an undetermined number of staff.

Findings include:

On 09/27/2022 at 11:23 am, review of sprinkler system inspection, testing, and maintenance reports, revealed that the facility was unable to confirm that dry sprinkler heads have been tested or replaced within the past 10-years. On 09/28/2022 at 9:42 am, observation at the loading dock / receiving revealed three sidewall dry sprinkler heads. Staff F stated it was unknown if the dry heads had been tested or replaced within the past 10-years.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff C, Staff F and Staff V.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 edition) Sections 19.3.6.3. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 09/28/2022 at 8:46 am, observation at the mechanical closet at the end of the patient room wing revealed a double door inactive leaf that included a manual flush bolt operator. This does not allow the corridor doors to positively latch.

2. On 09/28/2022 at 8:55 am, observation at the office door near the locker room revealed a Dutch door that uses a manual bolt to latch the top half to the bottom half. This does not allow the corridor door to positively latch.

3. On 09/28/2022 at 9:29 am, observation at the kitchen door in the corridor across from the conference room revealed that the double door did not positively latch both leaves.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff C, Staff F and Staff V.

Based on observation and interview, the facility did not provide a remote emergency stop button located outside of the emergency generator enclosure in accordance with the requirements of NFPA 110 (2010 edition) Section 5.6.5.6, NFPA 70 (2011 edition), Section 445.18. This deficiency had the potential to affect all of the residents, as well as an undetermined number of staff and visitors.

Findings include:

On 09/28/2022 at 9:34 am, observation at the generator revealed that there was an emergency stop button on the generator. There was no additional emergency stop button located remotely from the generator at the facility. The generator was installed in 2012.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff C, Staff F and Staff V.

K920 Power Cords and Extensions

Based on observations and staff interview, the facility failed to properly maintain electrical devices in accordance with NFPA 101 (2012 edition), Sections 19.5.1.1 and 9.1.2, and NFPA 70 (2011 edition) Sections 400.8, 590.2(B). This deficient practice could affect X of Y residents, as well as an undetermined number of staff and visitors.

Findings include:

On 09/28/2022 at 8:19 am, observation in the therapy office area, an extension cord was being used to power a window air-conditioner.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff F.