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Based on observation, the facility failed to properly post mandatory signs regarding the function of the delayed egress on the exit doors as required by the code in accordance with NFPA 101, 2012 Edition, Sections 19.2.2.2.4 and 7.2.1.6.1.

Findings include:

1. During an observation on 9/21/21 at 2:17 p.m., the exit door at the end of corridor 4 was inspected. The door was equipped with a wander guard system which locked the door via magnetic lock. The door was equipped with delayed egress, but there were no signs posted on the door instructing occupants on the use of the delayed egress locking system.

2. During an observation on 9/21/21 at 2:32 p.m., the exit door at the end of corridor 3 was inspected. The door was equipped with a wander guard system which locked the door via magnetic lock. The door was equipped with delayed egress, but there were no signs posted on the door instructing occupants on the use of the delayed egress locking system.

3. During an observation on 9/21/21 at 2:34 p.m., the exit door on corridor 2 was inspected. The door was equipped with a wander guard system which locked the door via magnetic lock. The door was equipped with delayed egress, but there were no signs posted on the door instructing occupants on the use of the delayed egress locking system.

4. During an observation on 9/21/21 at 2:44 p.m., the exit door for PT was inspected. The door was equipped with a wander guard system which locked the door via magnetic lock. The door was equipped with delayed egress, but there were no signs posted on the door instructing occupants on the use of the delayed egress locking system.

5. During an observation on 9/21/21 at 2:50 p.m., the ER exit door was inspected. The door was equipped with a wander guard system which locked the door via magnetic lock. The door was equipped with delayed egress, but there were no signs posted on the door instructing occupants on the use of the delayed egress locking system.

Based on observations and past survey information, the facility did not ensure that there were two acceptable remote exits provided in the basement.

The findings include:

During an observation on 9/21/21 at 12:59 p.m., and information from previous surveys, the interior stairway by the service elevator was not considered as an acceptable exit due to the lack of fire rated doors protecting its vertical openings. The stairway discharged onto the main or upper level and did not open onto an exit passageway.

NOTE: There are two other exits available, one from the basement directly to the exterior and one by means of a horizontal exit to the new laundry area. However, both of these exits were adjacent to each other and did not meet the criteria for being considered as remote from each other.

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. This affects all locations where the battery powered emergency light fixtures were utilized.

Findings include:

1. Review of the facility records for testing of the emergency lighting showed a lack of supporting documentation for 30 second monthly tests performed on the emergency light in the generator room in the last year.

Based on observation, the facility failed to ensure the interior stairwell was enclosed with self-closing doors having a 1-hour rating, per NFPA 101 Life Safety Code, 2012 Edition, Section 19.3.1.7.

Findings include:

1. During an observation on 9/21/21 at 1:31 p.m., the lower door of the interior stairwell was exercised twice. The door failed to close and latch under the power of self-closer.

Based on observation, the facility failed to ensure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 9/21/21 at 12:59 p.m., the covid storage and standpipe room were inspected. The door to the room would not close under the power of the self-closer. It was not flush in the frame, and it was not even able to be pulled shut to the latch.

2. During an observation on 9/21/21 at 1:04 p.m., the soiled side of the laundry was inspected. The corridor door to the room would not overcome the air imbalance and close and latch under the power of the self-closer.

3. During an observation on 9/21/21 at 2:27 p.m., room 9 was inspected. The room was being used and storage and it was over 50 square feet. The room was lacking the required self-closer.

Based on interview and record review, the facility failed to ensure all smoke detectors had tested for sensitivity in accordance with NFPA 72 National Fire Alarm and Signaling Code, 2010 Edition, Section 14.4.5.3.2. This deficiency affects all of the smoke compartments.

Findings include:

1. During record review on 9/21/21, records for the fire alarm and smoke detection systems were reviewed. The smoke detector sensitivities had not been completed within the last two years.

Based on observation, the facility failed to ensure the building was fully sprinkled, in a building of Type V (111) construction in accordance with NFPA 101, Life Safety Code, 2012 Edition, Section 19.3.5.1. The deficiency affects 1 of 3 smoke compartments.

Findings include:

1. During an observation on 9/21/21 at 2:36 p.m., the new laundry chute and the enclosed room at the top of the chute was inspected. The room was found to not have any sprinkler head protection.

Based on observation and record review, the facility

a) failed to 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,

b) failed to document monthly standpipe gauge readings per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1.

Findings include:

1. During an observation on 9/21/21 at 1:35 p.m., the elevator equipment room was inspected. There were many ceiling tiles out in the room.

2. During an observation on 9/21/21 at 2:21 p.m., the activity storage room was inspected. There was a ceiling tile out of the drop down ceiling in the room.

3. During an observation on 9/21/21 at 2:22 p.m., on corridor 4, the linen closet room 305 was found to be missing the escutcheon ring.

4. During an observation on 9/21/21 at 2:38 p.m., the custodial closet between corridors 2 and 3 was inspected. There was a ceiling tile out of the drop down ceiling in the room.

5. Review of facility documentation for the automatic sprinkler system on 9//21/21, reflected a lack of monthly pressure gauge checks on the wet sprinkler system.

Based on observation, the facility failed to ensure timely (every 5 years) hydrostatic testing for the K type extinguisher, located in the kitchen, in accordance with NFPA 101-2012, Section 9.7.4.1 and NFPA 10-2010, Section/Table 8.3.1 Hydrostatic Test Intervals for Extinguishers.

Findings include:

1. During an observation on 9/21/21 at 2:04 p.m., the kitchen was inspected. The K extinguisher was last hydrotested in March of 2015. The K tank was overdue for hydro testing as of March of 2021.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 8.3.3.1, 19.7.6, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

Findings include:

1. Review of the fire safety maintenance records on 9/21/21, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire barriers in the building and show inspections of all components of the fire doors in those barriers.

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).

These deficiencies affect 1 of 3 basement smoke compartments in the facility.

Findings include:

1. During an observation on 9/21/21 at 1:14 p.m., the boiler room was inspected. There was an outlet in the room missing the cover plate.

Based on record review, the facility failed to perform retention testing on the receptacles in patient areas.

Findings include:

Record review on 9/21/2021 revealed non-hospital grade receptacles located in resident rooms throughout the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on record review and interview, the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 110, Section 8.3.8. The deficiency affects the entire building.

Findings include:

1. Review of the emergency generator inspection records on 9/21/21, showed the annual diesel fuel supply quality test was not conducted within the last year.

During an interview on 9/21/21, staff member A stated the facility had not completed an annual fuel quality test for the generator.

Based on observation and interview, the facility failed to ensure extension cords were not used as a substitute for the fixed wiring of the facility per NFPA 70 National Electric Code, 2011 Edition, Section 400.8.

Findings include:

1. During an observation on 9/21/21 at 1:29 p.m., the basement storage area was inspected. There was a light balast connected to the building power supply via an extension cord.

2. During an observation on 9/21/21 at 1:55 p.m., the maintenance shop was inspected. There was a large refrigerator plugged into the building power supply via an extension cord.

Based on observation, the facility failed failed ensure oxygen storage rooms were lockable to unauthorized entry in accordance with NFPA 99 Health Care Facilities Code, 2012 Edition, Sections 11.3.2.1.

Findings include:

1. During an observation on 9/21/21 at 12:50 p.m., the basement oxygen storage room was inspected. The room was not lockable and there was not any means from keeping the room free from unauthorized entry.