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Based on observation and staff interview, the facility failed to provide unobstructed access to the means of egress as required by the Life Safety Code (NFPA 101) 2012 edition section 19.2.2 & 7.1.10.1. This deficient practice could affect the exiting ability of an undetermined amount of staff and visitors.

Findings include:

At 10:25 am on 08/08/2017 observations revealed the corridor in the receiving area on the lower level contained combustibles that were being stored on a permanent basis.

This deficient condition was confirmed by the Assistant Director of Maintenance.

Based on observation and staff interview the facility to maintain 4 hazardous storage rooms in accordance with the 2012 Life Safety Code (NFPA 101) section 19.3.2.1.3. This deficient condition could allow smoke or fire to enter the corridor making it untenable and affect the quick and efficient exiting for all of an undetermined amount of staff and visitors.

Findings include:

On the facility tour on 08/08/2017 observations revealed several storage rooms over 50 sq which contained combustibles did not have self closer's.
1. At 10:13 am observed the record storage room on the lower level.
2. At 10:20 am observed storeroom #2 on the lower level.
3. At 10:28 am observed the storeroom across from the plant office.
4. At 11:04 am observed the mattress storage room on the lower level.

This deficient condition was confirmed by the Assistant Director of Maintenance.

Based on observations, staff interview and record review the facility failed to identify the interior finish class of the walls in a storage room with combustible materials as stated in the Life Safety Code, NFPA 101 2012 edition sections 19.3.3.2. This deficient practice could create an additional fuel load in a fire condition and cause a fire to spread more quickly which could affect the exiting of all staff using the lower level.

Findings include:

At 11:20 am on 08/08/2017 observations revealed, the walls of the storage room across from the multi purpose room were covered with wood paneling that did not have documentation of its fire resistance rating.

This deficient condition was confirmed by the Assistant Director of Maintenance.

Based on observation and staff interview, the facility failed to test and maintain the sprinkler system in accordance with the 2012 Life Safety Code (NFPA 101) and NFPA 25 section 5.3.2 & 14.2. The standard for testing and maintenance of sprinkler systems. This deficient condition could cause the sprinkler system not to function properly and allow for the spread of fire. This could affect all of the patients and an undetermined amount of staff and visitors.

Findings include:

At 7:50 am on 08/08/2017 documentation review revealed there was no record of the last internal pipe inspection or of the last date of the calibration or replacement of the gauges on the riser.

This deficient condition was confirmed by the Assistant Director of Maintenance.

Based on observation and staff interview the facility failed to provide documentation of the required annual fire extinguisher inspections as required by the Life Safety Code, NFPA 101 2012 edition section 9.7.4.1 and NFPA 10, Portable Fire Extinguishers, sections 7.3.1.1.1 & 7.2.4.4. This deficient practice could render an extinguisher inoperable and affect patients and an undetermined amount of staff and visitors.

Findings include:

At 7:55 am on 08/08/2017 documentation review revealed there was no annual fire extinguisher report.

This deficient condition was confirmed by the Assistant Director of Maintenance.

Based on observation and staff interview the facility failed to provide a corridor door with a means suitable for resisting the passage of smoke in accordance with the 2012 Life Safety Code (NFPA 101) section 19.3.6.3.1 & 19.3.6.3.5. This deficient practice could allow for smoke to enter the corridor making it difficult to exit in the case of fire, affecting an undetermined amount of staff and visitors.

Findings include:

At 10:10 am on 08/08/2017 observations revealed the dutch doors on the shop did not have an astragal or rabbit between the door halves.

This deficient condition was confirmed by the Assistant Director of Maintenance.

Based on record review and staff interview the facility failed to maintain a Fire Safety Plan as required in NFPA 101 Life Safety Code, 2012 edition section 19.7.2.2. This deficient practice could cause confusion in an emergency and affect all patients and an undetermined amount of staff and visitors.

Findings include:

At 8:10 am on 08/08/2017 documentation review revealed the Life Safety Plan did not address all 9 items listed in the Life Safety Code.

This deficient condition was confirmed by the Assistant Director of Maintenance.

Based on record review and staff interview the facility failed to conduct fire drills as required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all patients and an undetermined amount of staff and visitors.

Findings include:

At 7:30 am on 08/08/2017 documentation review revealed the fire drills were not being conducted separately from the attached nursing home.

This deficient condition was confirmed by the Assistant Director of Maintenance.