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Based on observation and interview, the facility failed to maintain a two-hour fire resistance rating to separate health care occupancies, affecting one of 14 smoke compartments.

Findings include:

1. Observation on May 31, 2023, at 10:40 a.m., revealed the door to the business office building, located in the two-hour rated building separation, failed to self-latch when tested.

Interview with the facility nursing leadership and maintenance director on May 31, 2023, at 2:00 p.m., confirmed the above door did not self-latch at the time of the survey.

Based on observation and interview, the facility failed to maintain doors with closing devices, affecting two of 14 smoke compartments.

Findings include:

1. Observation on May 31, 2023, at 11:45 a.m., revealed the doors between the kitchen and the dining room failed to latch when tested.

Interview with the facility nursing leadership and maintenance director on May 31, 2023, at 2:00 p.m., confirmed the above door deficiencies.

Based on observation and interview, the facility failed to install and maintain the kitchen hood extinguishing system, affecting one of 14 smoke compartments, in accordance with NFPA 96, 12.1.2.3. and 12.1.2.3.1.

Findings include:

1. Observation on May 31, 2023, at 12:45 p.m., revealed the wheeled gas-fired oven and the gas cook-top/oven in the kitchen were not equipped to be returned to an approved design location after maintenance and cleaning.

2. Observation on May 31, 2023, at 12:48 p.m., revealed there was no inspection tag on the ansul pull station to document monthly inspections.

Interview with the facility nursing leadership and maintenance director on May 31, 2023, at 2:00 p.m., confirmed the above kitchen deficiencies.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system, affecting one of 14 smoke compartments.

Findings include:

1. Observation on May 31, 2023, at 10:30 a.m., revealed a gap around piping in the pharmacy ceiling that measured more than 1/8".

Interview with the facility nursing leadership and maintenance director on May 31, 2023, at 2:00 p.m., confirmed the above automatic sprinkler system deficiency.

Based on observation and interview, the facility failed to maintain corridor doors for one of over 200 corridor doors inspected.

Findings include:

1. Observation on May 31, 2023, at 9:46 a.m., revealed the room 220 echo cardiology door had four holes present that could allow the passage of smoke.

Interview with the facility nursing leadership and maintenance director on May 31, 2023, at 2:00 p.m., confirmed the above unsealed corridor door penetrations.

Based on document review and interview, the facility failed to perform the required annual fire door assembly inspection, affecting the entire facility.

Findings include:

1. Review of documentation on May 31, 2023, at 9:15 a.m., revealed the facility lacked annual fire door assembly inspection documentation.

Interview with the facility nursing leadership and maintenance director on May 31, 2023, at 9:15 a.m., confirmed the facility lacked the above documentation.

Based on observation and interview, the facility failed to maintain electrical receptacles for three of over 200 receptacles.

Findings include:

1. Observation on May 31, 2023, revealed the following electrical outlets, located within six feet of sinks, were not protected by ground fault circuit interruptors (GFCIs):

a) 9:37 a.m., Respiratory health break room on the third floor;
b) 9:40 a.m., Waiting room 204 restrooms on the second floor;
c) 9:48 a.m., Break room 218 on the second floor.

Interview with the facility nursing leadership and maintenance director on May 31, 2023, at 2:00 p.m., confirmed the above electrical receptacle deficiencies.

Based on document review and interview, the facility failed to perform emergency generator maintenance testing for 12 of 12 months.

Findings include:

1. Review of documentation on May 31, 2023, revealed the following:
a) 9:30 a.m., The facility lacked documentation for the annual preventative maintenance of the emergency generator;
b) 9:35 a.m., The facility lacked documentation for the annual fuel quality test on the emergency generator.

Interview with the facility nursing leadership and maintenance director on May 31, 2023, at 9:35 a.m., confirmed the required annual generator testing documentation was not available at the time of the survey.

Based on observation and interview, the facility failed to maintain electrical equipment and power cords, affecting one of 14 smoke compartments.

Findings include:

1. Observation on May 31, 2023, at 10:15 a.m., revealed a microwave and refrigerator were plugged into a power strip in the central scheduling office on the first floor.

Interview with the facility nursing leadership and maintenance director on May 31, 2023, at 2:00 p.m., confirmed the above misuse of electrical equipment.