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Based on observation and staff interview, the facility failed to ensure a door in the path of egress could be opened with 15 lbf in 1 of 9 smoke compartments. This condition would slow the evacuation of all occupants in the smoke zone, which would affect approximately 9 occupants. The facility has the capacity for 25 beds with a census of 3 on the day of survey.

Findings are:
Observation on 8/09/23, at 10:44 am revealed the emergency exit for acute care south required over 15 lbf to open.

In an interview on 8/09/23, at 10:44 am Maintenance A acknowledged the door required greater than 15 lbf of force to open.

Based on observation and interview, the facility failed to ensure an emergency exit sign was functional. This deficient practice had the potential to inhibit the ability of residents and staff to locate the exit. This deficient practice would affect approximately 9 occupants. The facility has the capacity for 25 beds with a census of 3 on the day of survey.

Findings are:
Observation on 8/09/23 at 10:48 am revealed the exit sign for the hallway between the dining room and acute care failed to illuminate.

During an interview on 8/09/23 at 10:48 am Maintenance Staff A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain doors to ensure smoke separation of the egress corridor in 2 of 9 smoke compartments. This condition would allow smoke and fire gases to migrate from one smoke compartment to another, which would affect approximately 15 occupants. The facility capacity was 25, with a census of 3 on the date of survey.

Findings are:
Observation on 8/9/2023 at 10:27 am revealed that the door to the Northwest Corridor fire separation doors had positive latching hardware and failed to latch in the closed position.

During an interview on 8/9/2023 at 10:27 am, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility allowed the use of a light duty multiplug adaptor as a substitute for permanent electrical wiring. This deficient practice could cause electrical injury and fires affecting approximately 10 occupants in 1 of 9 smoke compartments. The facility capacity was 25, with a census of 3 on the day of survey.

Findings are:

Observation on 8/9/2023 at 10:36 am revealed the use of a light duty, un-grounded extension multiplug adaptor to power a TV in east wing room 32.

During an interview on 8/9/2023 at 10:36 am, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility failed to assure that compressed gas cylinders were stored in an approved area. This deficient practice would allow an oxygen-enriched atmosphere and increase the potential for a fire. This would affect approximately 9 occupants. The facility has the capacity for 25 beds with a census of 3 on the day of survey.

Observation on 8/9/2023 at 10:42 am revealed that 14 oxygen cylinders were stored in a room without a fire rated door

During an interview on 8/9/2023 at 10:42 am, Maintenance Staff A confirmed cylinders were stored in a room without a fire rated door.

NFPA 99, 5.1.3.3.2* Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:
(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1.

(2) They shall be secured with lockable doors or gates or otherwise secured.

(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits.

(4) If indoors, they shall be constructed and use interior fiishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating.

(5)*They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations.

(6) They shall be heated by indirect means (e.g., steam, hot water) if heat is required.

(7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty.

(8)*They shall be supplied with electrical power compliant with the requirements for essential electrical systems as described in Chapter 6.

(9) They shall have racks, shelves, and supports, where provided, constructed of noncombustible materials or limited-combustible materials. (10) They shall protect electrical devices from physical damage