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Based on observation, the facility failed to maintain the exit discharge per the requirements of:

2012 NFPA 101, 19.2.1, and 7.7.3.2

This deficiency affects 1 of 7 exits.

Findings include:

During a tour of the facility, the surveyor observed the exit discharge to the public way at rooms 227 and 228 was not arranged and marked to make clear the direction of egress travel from the exit discharge to public way. This exit discharge passed through an outside covered sitting/smoking area.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a hazardous room per the requirements of:

2012 NFPA 101, 19.3.2.1.2, and 8.4.2 (3) (a)

This deficiency affects 2 of 4 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed Mechanical Room #4 had a gas boiler and an unsealed penetration around a 1 1/2" conduit through the South (2 hour fire barrier) wall.

A member of maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the kitchen hood per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 5.1.2, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1

This deficiency affects the kitchen hood.

Findings include:

During a tour of the facility, the surveyors observed the facility failed to provide the following:

1. An approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location.
2. A liquidtight continuous external weld to the kitchen hood's seams and/or joints, that direct and capture grease-laden vapors and exhaust gases.

A member of maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the smoke detectors per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 14.4.5.3.2

This deficiency affects the entire facility.

Findings include:

During a tour of the facility, the facility failed to provide a smoke detector sensitivity test report completed within the past two years. The facility failed to provide the last documented smoke detector sensitivity test.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to install quick-response sprinklers per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1)
2010 NFPA 13, 8.3.3.2, and 8.3.3.4

This deficiency affects the Emergency Department Waiting Room.

Findings include:

During a tour of the facility, the surveyor observed one quick-response sprinkler had been installed in the same compartment (the Emergency Department Waiting Room) with 5 standard-response sprinklers.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 14.2.1

This deficiency affects the automatic sprinkler system.

Findings include:

During the review of the documentation, the facility failed to provide documentation of conducting the automatic sprinkler internal pipe inspection during the past 5 years.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on observation, the facility failed to maintain the corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.4

This deficiency affects two residents' rooms corridor doors.

Findings include:

During a tour of the facility, the surveyor observed residents' rooms 217 and 218 corridor doors had an approximately 3/4 in. gap between the door and door frame when door was fully closed; prohibiting the door from being smoke resistive.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the permitted smoking area per the requirements of:

2012 NFPA 101, 19.7.4 (6)

This deficiency affects 1 of 1 smoking areas.

Findings include:

During a tour of the facility, the surveyor observed the residents' medical detox unit permitted smoking area was without a metal container with self-closing cover device:

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 of 4 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed a portable space heating device on a night stand next to a bed in the Doctors Lounge, this device was not on. This was located in a patient sleeping smoke compartment and the facility was unable to provide documentation that the heating element did not exceeding 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the piped medical gas and vacuum systems per the requirements of:

2012 NFPA 99, 5.1.14.2.3

This deficiency affects all of the piped medical gas and vacuum systems.

During a tour of the facility, the facility failed to provide documentation of the annual inspection for the piped medical gas and vacuum systems for the past 12 months.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to provide a remote manual stop station for the emergency generator per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.2.4
2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1

This deficiency affects 1 of 1 emergency generator.

Findings include:

During a tour of the facility, the facility failed to provide a labeled, remote manual stop station (of a type to prevent inadvertent or unintentional operation) located outside the room housing the generator, for the 210 kW emergency generator.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the oxygen manifold cylinder storage area per the requirements of:

2012 NFPA 99, 11.6.2.3 (11), 11.3.2.3 and 11.6.5.4

This deficiency affects 1 of 1 outside oxygen manifold cylinder storage areas.

Findings include:

During a tour of the facility, the facility failed to protect the outside oxygen manifold cylinder storage area against continuous exposure to direct rays of the sun where extreme temperatures prevail.

A member of the maintenance staff was present when this deficiency was identified.