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Based on observation the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2.

This deficiency affected 1 out of 2 smoke compartments in the facility.

Findings include:

During an observation on 5/28/24 at 12:10 p.m., the employee restroom was inspected. The door was fitted with a lock that required two motions to unlock.

Based on record review the facility failed to provide emergency lighting per NFPA 101-2012, Sections 18.2.9.1 and 7.9.3.1.1 (3)

This deficiency affects the entire facility.

Findings include:

Review of the facility's maintenance records did not show an annual 90-minute test had been completed for the facility's emergency lighting.

Based on record review the facility failed to provide emergency lighting per NFPA 101-2012, Sections 19.2.9.1 and 7.9.3.1.1 (3)

This deficiency affects the entire facility.

Findings include:

Review of the facility's maintenance records did not show an annual 90-minute test had been completed for the facility's emergency lighting.

Based on an observation the facility failed to provide exit signage in accordance with NFPA 101-2012, Section 7.10.2.1.

This deficiency affects 1 of 2 smoke compartments.

Findings Include:

During an observation on 5/28/24 at 12:35 p.m., the ER hallway was inspected. A directional exit sign was not present in the hallway directing occupants which direction to travel to the nearest exit.

Based on observation, the facility failed to ensure an alcohol-based hand rub (ABHR) dispenser was not mounted within 1 inch of an ignition source in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8 b).

This deficiency affects 1 out of 2 smoke compartments in the facility.

Findings include:

During an observation on 5/28/24 at 11:41 a.m., the kitchen was inspected. A hand sanitizer pump was installed within one inch of an ignition source.

Based on observation the facility did not have fire suppression sprinklers serving all areas of the facility per NFPA 101, 2012 Edition, Section 19.1.6.1 and Table 19.1.6.1.

This deficiency affected 1 out of two smoke compartments in the facility.

Findings include:

During an observation on 5/28/24 at 11:46 a.m. the east entrance canopy was inspected. There was a canopy outside the east entrance that did not have any suppression. Type II (111) building construction needs to have fire suppression throughout.

Based on observation and record review the facility failed to:

a) complete monthly standpipe gauge readings for the wet system per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1.,

b) 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)., and

c) maintain escutcheon plates around sprinkler heads in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 6.2.7.1.

This deficiency affects all residents and staff at the facility.
Findings include:

1.Review of the facility's maintenance records showed monthly documentation of the wet sprinkler system pressure gauges was not being documented.

2. During an observation on 5/28/24 at 11:32 a.m., the back-up boiler room was inspected. A ceiling tile was sagging creating gapping around the ceiling.

3. During an observation on 5/28/24 at 12:11 p.m. the PT entrance hall was inspected. There were three perforations in the ceiling tiles.

4. During an observation on 5/28/24 at 12:46 p.m. the server room was inspected. There was a broken ceiling tile.

5. During an observation on 5/28/24 at 12:09 p.m. room 104-A was inspected. Two missing escutcheon rings were missing on sprinkler heads in the room.

6. During an observation on 5/28/24 at 12:45 p.m. the doctor's office was inspected. There was a missing escutcheon ring on a sprinkler head in the room.

Based on record review the facility failed to complete monthly standpipe gauge readings for the wet system per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1.,

This deficiency affects all residents and staff at the facility.

Findings include:

Review of the facility's maintenance records showed monthly documentation of the wet sprinkler system pressure gauges was not being documented.

Based on observation and interview the facility failed to install portable fire extinguishers in accordance with NFPA 101 Life Safety Code 2012 Edition, Sections 19.3.5.12, and NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Sections 6.1.3.4 and 6.1.3.8.1.

This deficiency affects all residents and staff of the facility.

Findings include:

During an observation on 5/28/24 at 11:38 a.m. the generator room was inspected. There was a fire extinguisher mounted 5 feet 7 inches off the ground.

During an interview on 5/28/24 at 11:39 a.m., staff member C stated most of the fire extinguishers in the building will be mounted too high. Staff member C stated he will have to move them all to the proper height.

During an observation on 5/28/24 at 11:43 a.m. the kitchen was inspected. There were two fire extinguishers mounted more than 5 feet off the ground.

During an observation on 5/28/24 at 12:43 p.m., the surgery suite was inspected. A fire extinguisher was mounted more then 5 feet off the ground.

During an observation on 5/28/24 at 12:47 p.m., the server room was inspected. A fire extinguisher was free standing on the floor of the room.

During an observation on 5/28/24 at 12:52 p.m., the south entrance was inspected. A fire extinguisher was mounted more then 5 feet off the ground.

Based on observation the facility failed to maintain corridor door openings in accordance with NFPA 101, 2012 Edition, Section 18.3.6.3.10.

This deficiency affects all smoke compartments in the building.

Findings include:

During an observation on 5/28/24 at 5:37 p.m. the dictation room was inspected. The corridor door was held open by a rubber wedge.

During an observation on 5/28/24 at 5:38 p.m. the isolation room was inspected. The corridor door was held open by a rubber wedge.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 18.7.1.6 and 18.7.2.2.

This deficiency affects all residents and staff at the facility.

Findings include:

1.During a review of facility fire drills on 5/28/24 it was determined the facility was missing the following fire drills:
The evening shift of the second quarter of 2023 (April-June)
The evening shift of the fourth quarter of 2023 (October - December)
The evening shift of the first quarter of 2024 (January - March)

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6 and 19.7.2.2.

This deficiency affects all residents and staff at the facility.

Findings include:

1.During a review of facility fire drills on 5/28/24 it was determined the facility was missing the following fire drills:
The evening shift of the second quarter of 2023 (April-June)
The evening shift of the fourth quarter of 2023 (October - December)
The evening shift of the first quarter of 2024 (January - March)

Based on observation and interview the facility failed to keep soiled linen receptacles greater than 32 gallons in an area protected as hazardous in accordance with NFPA 101, 2012 Edition, Section 19.7.5.7.1.

This deficiency affects 1 of 2 smoke compartments in the facility.

Findings include:

During an observation on 5/28/24 at 11:54 a.m. the 200 hallway was inspected. There was a 50-gallon soiled linen container in the hallway.

During an interview on 5/28/24 at 11:55 a.m. staff member C stated there will be multiple containers like that in the hallway. Staff member C stated they are used for trash or soiled linen.

During an observation on 5/28/24 at 12:01 p.m. the hallway by room 202 was inspected. There was a 50-gallon soiled linen container in the hallway.

Based on record review and interview the facility failed to ensure piped oxygen shutoff valves were properly labeled in accordance with NFPA 99 Healthcare Facilities Code 2012 Edition, Section 5.3.11.2.

This deficiency affected 1 out of 2 smoke compartments in the facility.

Findings include:

During an observation on 5/28/24 at 12:36 p.m., the ER hallway was inspected. There was a medical gas shut off valve located on the wall. There was no label on the shut off valve indicating the room(s) or area(s) served.

During an interview on 5/28/24 at 12:37 p.m., staff member C stated that piped oxygen was being used and was not sure what areas the shut off valve served.

Based on an observation the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

This deficiency affects 1 out of 2 smoke compartments in the facility.

Findings include:

During an observation on 5/28/24 at 12:47 p.m., the server room was inspected. There was storage located in front of the electrical panel.

Based on observation, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B).

This deficiency affected 1 out of 2 smoke compartments.

Findings include:

During an observation on 5/28/24 at 12:46 p.m. the server room was inspected. Two outlets were missing cover plates.

Based on observation, the facility failed to maintain the proper signage for the storage room for oxygen cylinders in accordance with NFPA 99, 2012 Edition, Section 5.1.3.1.9.

This deficiency affects 1 out of 2 smoke compartments.

Findings include:

During an observation on 5/28/24 at 12:53 p.m., the oxygen storage room was observed. There was signage located on the door, but it was illegible. The signage was painted over.