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Based on observation and staff interview, it was determined the facility failed to ensure that hazardous areas are protected and separated from other spaces in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

On 03/29/22 at approximately 1:10 p.m., building tour revealed the storage room on the right side of the corridor in the tunnel to the connector building has double doors that are not rated and equipped with non-rated hardware.

On 03/29/22 at approximately 1:15 p.m., building tour revealed the storage room on the left side of the corridor in the tunnel to the connector building has double doors that are not rated and equipped with non-rated hardware.

On 03/30/22 at approximately 10:20 a.m., these findings were discussed with the Maintenance Supervisor and Administrator upon exit.

Based on observation and staff interview, it was determined the facility failed to ensure the fire alarm system was maintained in accordance with NFPA (National Fire Protection Association) 72. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

On 03/29/22 at approximately 2:20 p.m., building tour revealed the smoke detector had been removed from the record storage room on the right side of the corridor in the connector tunnel.

On 03/30/22 at approximately 10:20 a.m., this finding was discussed with the Maintenance Supervisor and Administrator upon exit.

Based on document review and staff interview, it was determined the facility failed to ensure the sprinkler system was maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

On 03/28/22 at approximately 3:20 p.m., document review revealed the facility failed to provide documentation of a five (5) year internal sprinkler pipe inspection.

On 03/30/22 at approximately 10:20 a.m., this finding was discussed with the Maintenance Supervisor and Administrator upon exit.

Based on document review and staff interview, it was determined the facility failed to maintain fire doors in accordance with NFPA (National Fire Protection Association) 80. Facility Census 7.

Findings include:

On 3/28/22 at approximately 2:45 p.m., review of documentation revealed the facility failed to provide documentation of testing and maintenance of fire door assemblies.

On 3/30/22 at approximately 10:20 p.m., this finding was discussed with the Maintenance Supervisor and Administrator upon exit.

Based on observation and staff interview, it was determined the facility failed to maintain electrical wiring in accordance with NFPA (National Fire Protection Association) 70. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

On 03/29/22 at approximately 8:00 a.m., tour of the boiler room revealed the facility failed to provide junction box covers on two (2) electrical junction boxes located in the ceiling of the boiler room.

On 03/29/22 at approximately 8:05 a.m., tour of the boiler room revealed the facility failed to provide junction box covers on equipment connections located in the boiler room.

On 03/30/22 at approximately 10:20 a.m., these findings were discussed with the Maintenance Supervisor and Administrator upon exit.

Based on document review and staff interview, it was determined the facility failed to conduct maintenance and testing of receptacles at patient bed locations in accordance with NFPA (National Fire Protection Association) 99. Facility Census 7.

Findings include:

On 03/29/22 at approximately 12:20 p.m., document review revealed the facility failed to provide documentation of testing of receptacles at patient bed locations.

On 03/30/22 at approximately 10:20 a.m., this finding was discussed with the Maintenance Supervisor and Administrator upon exit.

Based on observation and staff interview, it was determined the facility failed to store all oxygen cylinders in accordance with NFPA (National Fire Protection Association) 99. Facility census 7.

Findings include:

On 03/29/18 at approximately 1:22 p.m., observation of the oxygen storage area revealed oxygen cylinders were not stored properly, and empty and full cylinders were stored together.

On 3/30/22 at approximately 10:20 p.m., this finding was discussed with the Maintenance Supervisor and Administrator upon exit.