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Based on observation and staff interview, the facility failed to maintain a clear path of egress system per NFPA 101 (2012 edition), Life Safety Code, sections 19.2.1 and 7.1.10.1. This deficient finding could have a patterned impact on the residents within the facility.

Findings include:

On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that there was rehabilitation equipment in the egress pathway leading into the rehabilitation area by exit door 815. this pathway must remain clear at all times for the safety of those in the area.

An interview with the Plant Operation Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a clear path of egress system per NFPA 101 (2012 edition), Life Safety Code, sections 19.2.1 and 7.1.10.1. This deficient finding could have a patterned impact on the residents within the facility.

Findings include:

On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that there was medical equipment stored in the egress exit door 815. This exit was blocked with a patient walker and will need remain cleared at all times.

An interview with the Plant Operation Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have a patterned impact on the residents within the facility.

Findings include:

On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that lower level maintenance storage room did not have a self-closing device.

An interview with the Plant Operation Director verified these deficient findings at the time of discovery.

Based on a review of available documentation, staff interview, and observations, the facility failed to maintain the fire alarm system per NFPA 101 (2012 edition), Life Safety Code, sections 9.6.1.3, 9.6.7.5, and NFPA 72 (2010 edition), National Fire Alarm and Signaling Code, sections 10.12.4, 14.3.1, 14.4.5.3, and 14.6.2.4. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/20/2024, between 09:00am and 1:00pm, it was revealed by a review of available fire alarm test and inspection documentation and an interview with the Environmental Services Director that the facility could not provide current documentation verifying that a monthly inspection had been completed for the month of July for the battery operated initiating devices.

An interview with the Plant Operation Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility.

Findings include:

On 08/20/2024, between 1:00pm and 3:00pm, it was revealed by observation that wooden wall type structure had been placed on a desk structure, bringing the combustible materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in dental office waiting room.

An interview with Plant Operation Directorverified these deficient findings at the time of discovery

Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that there was a penetration running from one smoke compartment to another above doors in the following areas:

1) Above Fire Doors leading into annex by the business office
2) Above Fire Doors leading into rehabilitation area
3) Above Fire Doors leading into surgical wing
4) Above Fire Doors leading into Lab/X-Ray
5) Above Fire Doors in P.D. Doctors Sleeping Lounge
6) Above Fore Doors to Link

An interview with the Plant Operation Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to secure electrical panels per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.3.2.2.1.3 and failed to maintain the Gas and Utility System per NFPA 101 (2012 edition), Life Safety Code section 9.2.2 and NFPA 54 (2012 edition), National Fuel Gas Code, sections 9.2.2 and 10.3.2.2. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that the electrical panel LP - N102 was not locked.

An interview with the Plant Operation Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to implement its portable space heater policy per NFPA 101 (2012 edition), Life Safety Code, section 19.7.8. These deficient findings could have a patterned impact on the residents within the facility.

Findings include:

On 08/20/2024, between 1:00pm and 3:00pm, it was revealed by observation of portable space heaters in the following areas;

1) In dental office employee room / office area near patient care area
2) in patient care area by dental chair
3) in oxygen storage area

"space heaters in or near patient care areas are prohibited".

An interview with Plant Operation Director verified these deficient findings at the time of discovery

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in the following areas:

1) Surgery refrigerator plugged into power-strip
2) Outpatient managers Office - refrigerator and microwave plugged into power-strip
3) Office 267D power-strip pugged into power-strip


An interview with the Plant Operation Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 08/20/2024, between 1:00pm and 3:00pm, it was revealed by observation that there were several electrical appliances plugged power-strips, multi-plug adapters and/or extension cords in the following areas;

1) 3 x Outlet Multi-plug adapter in oxygen storage area
2) 6 x Outlet Multi-plug adapter in oxygen storage area

An interview with the Plant Operation Director this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to store oxygen cylinders per Health Care Facilities Code NFPA 99 (2012 Edition), sections 11.3.2.3, 11.6.5.2 and 11.6.5.3. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 08/20/2024, between 09:00am and 1:00pm, it was revealed by observation that oxygen is being stored in X-Ray corridor was not secured while not in use.

An interview with the Plant Operation Director verified these deficient findings at the time of discovery.