HospitalInspections.org

Based on observation, and staff interviews it was determined the facility failed to properly maintain exit locking devices.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed the following:
1) Multiple locking devices that require more than one operation are located on all exit doors including but not limited to the following doors:
A) Counselling Office outside,
B) Group B Councelling Office
C) Receptionist Office
D) Back door counseling offices (2)
2) Exit through the Directors office is subject to locking.

These findings were confirmed by Staff M at the time of discovery.

Reference:
1) 2012 NFPA 101 Chapter 39, Section39.2.1.1, Chapter 7, Section 7.2.1.5.10.2
2) 2012 NFPA 101, Chapter 39, Section 39.2.1.1, Chapter 7, Section 7.5.2.1

Based on observation, and staff interviews it was determined the facility failed to properly maintain locking devices on exit doors.

This could place 34 patients and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed the following:
1) C wing exit door has a double keyed deadbolt lock.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.2.2.2.4

Based on observation, and staff interviews it was determined the facility failed to properly maintain exit locking devices on 2 of 2 exit doors.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed the following:
1) Multiple locking devices that require more than one operation are located on all exit doors including but not limited to the following doors:
A) Main Front Exit
B) Back Exit Door

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101 Chapter 39, Section39.2.1.1, Chapter 7, Section 7.2.1.5.10.2

Based on observation, and staff interviews it was determined the facility failed to properly maintain clear exit width.

This could place all staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that the B wing Nurses station corridor does not maintain clear width.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, 19.2.3.4, 19.2.1, 7.1.10.1, 7.1.10.2.1

Based on observation, review of facility records, and staff interviews it was determined the facility failed to provide emergency lighting for the exit discharge at 5 of 5 exits.

This could place all residents and staff at risk in the event of fire or electrical emergency.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed that none of the exits are provided with emergency lighting that luminates the exit discharge to a public way.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.2.9.1 and Chapter 7, Sections 7.9.1.1(1) and 7.9.1.2

Based on observation, review of facility records, and staff interviews it was determined the facility failed to provide emergency lighting for the exit discharge.

This could place all residents and staff at risk in the event of fire or loss of electrical power.
.
The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that none of the exits discharge were provided with emergency lighting to a public way.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.2.9.1 and Chapter 7, Sections 7.9.1.1(1) and 7.9.1.2

Based on observation, and staff interviews it was determined the facility failed to properly install/provide exit signs.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed that the exit sign in the middle of the corridor is not aproved exit sign.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 39, Section 39.2.10, and Chapter 7, Section 7.8.1.1, Section 7.10

Based on observation, and staff interviews it was determined the facility failed to properly maintain doors to hazardous areas.

This could place kitchen staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed that the kitchen dry storage room door does not close and latch.

These findings were confirmed by Staff M at the time of discovery.

Reference:

Based on observation, and staff interviews it was determined the facility failed to properly maintain hazardous areas.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed the following:
1) Mechanical room has two holes that are filled with srpray foam.

2) The following rooms or areas have doors that do not close and latch properly:
A) Kitchen supply door does not close and latch.
B) Cleaning supply in the Kitchen door does not close and latch.
C) B Wing Bio-Hazard door does not close and latch and door has a door hold open kick on the bottom of the door.
D) B Wing Med-Storage room door has a door hold open kick on the bottom of the door.

3) The following rooms or areas are being used for storage and doors are not provided with self closing devices:
A) Administrative Assistant of Maintenance
B) Room A-10 is being used for storage and door is not equipped with a self closing device.
C) Shower room at exam room is being used for storage and door is not equipped with a self closing device.
D) B Wing West confiscation closet is used for storage and door is not equipped with a self closing device.
E) Room B-10 is being used for storage and door is not equipped with a self closing device.
F) Room #12 is being used for storage and door is not equipped with a self closing device.
G) Medical records storage room/office door is not equipped with a self closing device.

4) The following areas are not maintained as smoke tight.
A) Pharmacy storage/office has 2 areas where holes are in the wall behind the desk and area is not smoke tight.
B) IT room has multiple holes in the wall and is not smoke tight.


These findings were confirmed by Staff M at the time of discovery.

Reference:
1) 2012 NFPA 101, 19.3.2.1, 19.3.2.1.2, 19.3.2.1.5, 8.4.4, 8.4.5
2) 2012 NFPA 101, 19.3.2.1.2, 8.4.3.2, 7.2.1.8.1, 7.2.1.8.2
3) 2012 NFPA 101, Chapter 19, Section 19.3.2.1.3
4) 2012 NFPA 101, Chapter 19, Sections 19.3.2.1 and 19.3.2.1.5 and Chapter 8, Sectons 8.7.1.1 and 8.3.5

Based on observation, and staff interviews it was determined the facility failed to properly maintain hazardous areas.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed the following rooms are being used for storage and are not seperated with approved fire barriers or sprinklered and smoke tight and doors do not have self closing devices.
1) Tech office
2) IT/Chart room

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 39, Sections 39.3, 39.3.2.1

Based on observation, and staff interviews it was determined the facility failed to properly install the fire alarm system.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed the following:
1) Smoke detector in the essential supply room is located the close to an HVAC vent/grill.
2) Fire alarm breaker located in electrical panel labeled L-2 is not:
A) Labeled in Red
B) Is not provided with a breaker lock.
C) Is not on a dedicated circuit.

These findings were confirmed by Staff M at the time of discovery.

Reference:
1) 2012 NFPA 101, Chapter 19, Section 19.3.4.2.1, Chapter 9, Section 9.6.2.1, Chapter 4, Section 4.5.7, Chapter 2, Section 2.2
and 2010 NFPA 72, Chapter 17, Section 17.7.6.3.2
2-A & B) 2012 NFPA 101, 19.5.1.1, 9.1.2 and 2011 NFPA 70, 760.41(A)(B)
or 2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 10.5.5.2.1 thru 10.5.5.2.4
2-C) 2012 NFPA 101, Chapter 19, Section 19.3.4.1, Chapter 9, Section 9.6, Section 9.6.1.3, and
2010 NFPA 72 Chapter 10, Section 10.5, Section 10.5.5.1

Based on observation, and staff interviews it was determined the facility failed to properly maintain the fire alarm system.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that the fire alarm control panel breaker in the C wing Nurses station does not have a breaker lock and is not labeled in red to identify fire alarm breaker.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, 19.5.1.1, 9.1.2 and 2011 NFPA 70, 760.41(A)(B) or 2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 10.5.5.2.1
thru 10.5.5.2.4

Based on observation, and staff interviews it was determined the facility failed to properly maintain the fire alarm system.

This could place 55l residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that smoke detectors in the following areas are located closer than 36 inches to air registers/grills:
1) Smoke detector #67 in B Hall.
2) Smoke detector in B Wing Nurses station.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.4.2.1, Chapter 9, Section 9.6.2.1, Chapter 4, Section 4.5.7, Chapter 2, Section 2.2
and 2010 NFPA 72, Chapter 17, Section 17.7.6.3.2, 17.7.4.1

Based on observation, and staff interviews it was determined the facility failed to properly maintain the fire alarm system.

This could place staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed the following:
1) No sensitivity testing of smoke detectors is documented within the last 2 years for review.
2) Horn/strobe in the staff conference room is missing a cover.

These findings were confirmed by Staff M at the time of discovery.

Reference:
1) 2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 14.4.5.3.1, 14.4.5.3.2
2) 2012 NFPA 101, Chapter 19, Section 19.3.4., Chapter 9, Section 9.6.1.3, and 2010 NFPA 72, Chapter 18, Section 18.3.4.1

Based on review of facility records, and staff interviews it was determined the facility failed to properly maintain the fire alarm system.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that no documentation is provided to verify that smoke detectors have been sensitivity tested within the past two years.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, 19.3.4.1, 9.6.1.3, 2010 NFPA 72, 14.4.5.3.1, 14.4.5.3.2

Based on observation, and staff interviews it was determined the facility failed to properly maintain the sprinkler system.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that the sprinkler head in the sprinkler riser room is greater than 12 inches below the ceiling.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, 19.3.5.1, 9.7.1.1, 2010 NFPA 13, 8.6.4.1.1.1

Based on observation, and staff interviews it was determined the facility failed to properly maintain sprinkler system.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that sprinkler piping was supporting wiring and other external loads. The following areas are noted for reference but may not be all inclusive:
1) B wing above nurses station sprinkler pipe is supporting water lines.
2) C wing above nurses station sprinkler piping is supporting wiring in multiple locations.
3) Sprinkler riser room sprinkler piping is supporting wiring.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19 Sections 19.1.1.1.3, 19.3.5, 19.3.5.1, Chapter 9, Section 9.7.1.1, 9.7.5, Chapter 4, Section 4.6.12.1
2011 NFPA 25, Chapter 5, Section 5.2.2.2

Based on observation, and staff interviews it was determined the facility failed to properly maintain 3 of 19 corridor doors.

This could place 40 residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed that the corridor doors in the following areas are not closing and latching maintaining a smoke tight seal.
1) Room #10
2) Room #11,
3) Room #15

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101 Chapter 19, Section 19.3.6.3.5, 19.3.6.3.1

Based on observation, and staff interviews it was determined the facility failed to properly maintain corridors as smoke tight.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that louvers are installed in corridor walls in the following locations:
1) B Wing West Common Area
2) B Wing East Laundry
3) C Wing Laundry
4) Mail room door

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.6.4.1

Based on observation, and staff interviews it was determined the facility failed to properly maintain corridor doors.

This could place 28 residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed that corridor door at laundry room a louver installed in the door.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.6.4.1

Based on observation, and staff interviews it was determined the facility failed to properly maintain 3 of 3 smoke/fire barriers.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed the following:
1) All smoke/fire barriers throughout the building are not properly sealed with a listed fire stop system at the head of the wall where the wall meets the underside of the roof deck.
2) All smoke/fire barriers have multiple penetrations that are not properly sealed with a listed fire stop system.
3) Some smoke/fire barriers do not have access to properly inspect smoke/fire barriers.
The following areas are noted for reference:
A) Smoke/fire barrier seperating A Wing and D wing. The center A wing corridors doors are offset and there is no access to verify if smoke/fire barriers are continious down the corridor, and west side of the smoke/fire barrier is not accessible for inspection of the full length of the smoke/fire barrier.
B) Smoke/fire barrier seperating A wing and B wing.
C) Smoke/fire barrier seperating A wing and C wing.


These findings were confirmed by Staff M at the time of discovery.

Reference:
1, 2,) 2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2,
8.5.6.3, Chapter 4, Section 4.6.12.1
3) 2012 NFPA 101 , Chapter 19, Sections 19.1.1.1.3, 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.3,
Chapter 4, Section 4.6.12.1, 4.6.12.4, 4.6.12.5, and 2012 NFPA 99 Chapter 15 Section 15.2

Based on observation, and staff interviews it was determined the facility failed to properly maintain 3 of 3 smoke/fire barriers.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed the following:
1) All smoke/fire barriers throughout the building are not properly sealed with a listed fire stop system at the head of the wall where the wall meets the underside of the roof deck.
2) All smoke/fire barriers have multiple penetrations that are not properly sealed with a listed fire stop system.
3) Some smoke/fire barriers do not have access to properly inspect smoke/fire barriers.
The following areas are noted for reference:
A) Smoke/fire barrier seperating A Wing and D wing. The center A wing corridors doors are offset and there is no access to verify if smoke/fire barriers are continious down the corridor, and west side of the smoke/fire barrier is not accessible for inspection of the full length of the smoke/fire barrier.
B) Smoke/fire barrier seperating A wing and B wing.
C) Smoke/fire barrier seperating A wing and C wing.


These findings were confirmed by Staff M at the time of discovery.

Reference:
1, 2,) 2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2,
8.5.6.3, Chapter 4, Section 4.6.12.1
3) 2012 NFPA 101 , Chapter 19, Sections 19.1.1.1.3, 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.3,
Chapter 4, Section 4.6.12.1, 4.6.12.4, 4.6.12.5, and 2012 NFPA 99 Chapter 15 Section 15.2

Based on observation, and staff interviews it was determined the facility failed to properly maintain smoke/fire barriers.

This could place all residents at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 between 9:00 AM and 3:00 PM observation revealed the following:
1) Smoke/fire barrier above restroom at AHU#5 has:
A) Multiple penetrations that are not properly sealed.
B) The bottton of the attic wall is not continious below ceiling and a void is present that is not properly sealed with a listed fire stop system.
C) Verify that the gray caulking used is a listed fire stop material.
2) Smoke/fire barrier above room #5 has 2 penetrations that are not protected with a listed fire stop system.
3) Smoke/fire barrier above room #4 has:
A) Plumbing penetrations that are not protected with a listed fire stop system.
B) Outside corner where the wall turns has a penetration that is not sealed with a listed fire stop system.
4) Smoke/fire barrier above room #15 has 2 plumbing penetrations that are not properly sealed with a listed fire stop system.
5) Smoke/fire barrier above Group room #4 has:
A) Plumbing penetration that is not properly sealed with a listed fire stop system.
B) HVAC duct penetration that is not properly sealed with a listed fire stop system.
6) Smoke/fire barrier above Group room #3 has a gray pipe penetration that is not properly sealed with a listed fire stop system.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2,
8.5.6.3, Chapter 4, Section 4.6.12.1

Based on observation, and staff interviews it was determined the facility failed to properly maintain 1 of 2 pairs of smoke doors.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed that East fire door is not properly closing providing a smoke tight seal.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, 19.3.7.8, 8.5.4.4, 7.2.1.8.1

Based on observation, and staff interviews it was determined the facility failed to properly maintain electrical systems in accordance with NFPA 70 National Electric Code.

This could place all residents and staff at risk in the event of fire or electrical emergency.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed the following.
1) Label each circuit as to it's use in the the following room or area.
A) Mechanical room. Main panel and Sub-panel 2.
B) Sprinkler riser room ( 2 panel boxes).

2) Srip adapters are not mounted off of the floor in the following areas to prevent damage:
A) Maintenance Director's Office
B) Exam Room
C) Clinical Office
D) Director of Nursing Office
E) B Wing Nurse station office
F) B Wing Room #10
G) C Wing Dr. Office
H) C Wing Nurse Manager's office

3) Service cord on fan in the staff break room is run through the suspended ceiling grid.

4) Coverplates are not provided on the electrical receptacles, junction boxes, in the following areas:
A) Sprinkler riser room has an open junction box with no coverplate provided.
B) C Wing Dr. Office has a wall outlet with no cover plate provided.

5) Light fixture in the sprinkler riser room is not properly secured to the wall and supported.

6) Extension cords are being used as permanent wiring in the following locations:
A) Director of Nursing office
B) Admissions office (2).

7) Clear space is not provided in front of electrical panel boxes in the B West Nurses Station.

8) Unapproved cube adapter is being used in the admissions office.

These findings were confirmed by Staff M at the time of discovery.

Reference:
1) 2012 NFPA 101, Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 408.4, 725.30
2) 2012 NFPA 101, 19.5.1.1, 9.1.2 and 2011 NFPA 70, 380.12 (2)
3) 2012 NFPA Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 400.8
4) 2012 NFPA 101 Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 314.28 (C) and 110.27
5) 2012 NFPA 101 Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 110.13
6) 2012 NFPA Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 400.8
7) 2012 NFPA 101, Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 110.26
8) 2012 NFPA 101 Chapter 19, Section 19.5.1.1, Chapter 9 Section 9.1.2 and 2011 NFPA 70 Article 382,10©

Based on observation, and staff interviews it was determined the facility failed to properly maintain the electrical system in accordance with NFPA 70 National Electric Code.

This could place all residents at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 between 9:00 AM and 3:00 PM observation revealed that there is an open junction box without an approved cover plate located above the server room.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101 Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 314.28 (C) and 110.27

Based on observation, and staff interviews it was determined the facility failed to properly maintain the electrical systems in accordance with NFPA 70 National Electric Code.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed the following:
1) Electrical panel boxes are not provided with clear space for access to maintain panel boxes.
2) IT room has a wall receptacle which does not have a coverplate installed on it.

These findings were confirmed by Staff M at the time of discovery.

Reference:
1) 2012 NFPA 101, Chapter 39, Section 39.5.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 110.26
2) 2012 NFPA 101, Chapter 39, Section 39.5.1. Chapter 9, Section 9.1.2 and 2011 NFPA 70, Article 406.6

Based on observation, review of facility records, and staff interviews it was determined the facility failed to properly maintain electrical systems in accordance with NFPA 70 National Electric Code.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed the following:
1) Front office has a strip adapter plugged into a extension cord daisy chained/piggy backed into another strip adapter.
2) Wall receptacle in the front office is missing a coverplate.
3) Each breaker in the electric panel box is not labeled / identified as to its specific use.

These findings were confirmed by Staff M at the time of discovery.

Reference:
1) 2012 NFPA 101, Chapter 39 Section 39.5.1, Chapter 9 Section 9.1.2 and 2011 NFPA 70 Article 382.10(A), Article 400.8
2) 2012 NFPA 101, Chapter 39, Section 39.5.1. Chapter 9, Section 9.1.2 and 2011 NFPA 70, Article 406.6
3) 2012 NFPA 101, Chapter 39, Section 39.5.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 408.4, 725.30

Based on observation, review of facility records, and staff interviews it was determined the facility failed to provide quarterly fire drills to all employees.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed that all staff members are not documented as receiving training during quarterly fire drills.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Sections 19.7.1.4 through 19.7.1.7, 4.7.4, Sections 19.7.2.1 through 19.7.2.3.3

Based on review of facility records, and staff interviews it was determined the facility failed to properly document fire drill trainng of all staff.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that all staff is not documented as receiving training during quarterly fire drills.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Sections 19.7.1.4 through 19.7.1.7, 4.7.4, Sections 19.7.2.1 through 19.7.2.3.3

Based on observation, and staff interviews it was determined the facility failed to properly maintain 1 of 1 exterior smoking areas.

This could place 10 residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed the following:
1) Smoking areas is not provided with ashtrays of non-combustible materail and safe design,
2) Smoking areas are not provided with a metal container with self closing lid into which ashtrays can be emptied.

These findings were confirmed by Staff M at the time of discovery.

Reference:
1) 2012 NFPA 101 Chapter 19 Section 19.7.4
2) 2012 NFPA 101 Chapter 19 Section 19.7.4

Based on observation, review of facility records, and staff interviews it was determined the facility failed to properly maintain smoking areas.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that the smoking areas are not provided with Ashtrays of non-combustible material and safe design, and Metal containers with self closing lids to empty ashtrays in the following areas:
1) B Wing smoking area
2) C Wing smoking area

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101 Chapter 19 Section 19.7.4

Based on observation, and staff interviews it was determined the facility failed to Properly store oxygen cylinders.

This could place all residents and staff at risk in the event of fire.

The findings include:
During a tour of the facility with Staff M on
10/30-31/2018 between 10:00 AM on 10/30/18 and 6:30 PM on 10/31/18 observation revealed that the rooms used to store full and empty oxygen cylinders are not properly marked with correct signage. "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING".

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.2.4, Chapter 8, Section 8.7 and 2012 NFPA 99 Chapter 11, Sections 11.3.4.1
and 11.3.4.2

Based on observation, and staff interviews it was determined the facility failed to properly maintain rooms used for oxygen storage.

This could place all residents and staff at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on
11/01/2018 9:00 AM and 3:00 PM observation revealed that the clean linen room is used for storage of Oxygen cylinders and proper signage is not on the door. "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING".

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.2.4, Chapter 8, Section 8.7 and 2012 NFPA 99 Chapter 11,
Sections 11.3.4.1 and 11.3.4.2