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Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions, in the egress corridor, hinder occupant egress in emergency situations. This deficient practice could potentially affect 8 of 8 residents in the facility.

Findings:

During the facility tour on 3/2/2020, between the hours of 10:00a-4:00p observation revealed the corridor by the nurses station and back hall were not clear of obstructions or impediments to full instant use of the exit passage way.

Interview with Administrator revealed the facility was not aware that the exit in the corridor was obstructed.

Based on visual observation the facility failed to provide proper exit signage for all required exits. Exit signs provide a route for occupants to reach safety. The deficient practice had the potential to affect 8 of 8 residents.

Findings:

During the facility tour on 3/2/2020, between the hours of 10:00a-4:30p observation revealed the exit sign by x-ray and on the back hall did not function properly.


Interview with Administrator revealed the facility was not aware that the exit signs did not function properly.

Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 8 of 8 residents.

Findings:

During thefacility tour and record review on 3/2/2020, between the hours of 10:00a-4:30p observation revealed the hood suppression and cleaning were pastdue for there semi-annual inspection and cleaning.

Interview with Administrator revealed the facility was not aware the semi-annual inspection and cleaning were not conducted on the hoop suppression system.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 8 of 8 residents.

Findings:

During the facility tour and the record review on 3/2/2020, between the hours of 10:00a-4:30p observation revealed the fire alarm was past due for the annual certification.

Interview with Administrator revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 8 of 8 residents.


Findings:

During the facility tour on 3/2/2020, between the hours of 10:00a-4:30p observation revealed unsealed penetration in all barriers wall.

Interview with Administrator revealed the facility was not aware of unsealed penetration.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect 0 of 0 residents.

Findings:

During the facility tour on 3/2/2020, between the hours of 10:00a-4:00p observation revealed the hydroculator in therapy was not connected to a GCFI outlet.

Interview with Administrator revealed the facility was not aware that the hydroculator in therapy was not connected to a GCFI outlet.

Based on visual observation the facility failed to assure that the gas and vacuum piped system was inspected and tested in accordance with the requirements of NFPA 99. Activation of the system will provide needed oxygen to patients, which results in protection of life. This deficiency has the potential to affect 8 of 8 residents.

Findings:

During the facility tour and record review on 3/2/2020, between the hours of 10:00a-4:30p observation revealed the annual inspection had not been completed on the gas and vacuum piped system.

Interview with Administrator revealed the facility was not aware that the annual inspections had not been conducted on the gas and vacuum piped system.