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Based on observation and interviews, the facility failed to properly maintain exit egress as per NFPA 101 section 19.2.2.2.5.2. This standard deficiency practice affected entire facility on the day survey.

Findings include:

On July 11, 2017 between 10:20 AM and 2:00 PM, observation revealed the mean of egress deficiencies in the following areas of the facility:

1) Side exit door of the Senior Care Unit and the exit door near Room 108 had keyed locks. The staff did not obtain and did not have a key to the locks the exit doors in the Senior Care Unit and the exit door near Room 108.
2) The Recovery Area door and Bulb Room door contain locks that could not be unlatched from the room side.
3) The magnetic lock on the exit door from the Senior Care Area into the hospital re-engaged and lock when the fire alarm system was silenced.

Based on observations, the facility failed to properly protect hazardous areas as per NFPA 101 section 19.3.2.1.2 and NFPA 101 section 8.4.2. This standard deficiency practice affected entire facility on the day survey.

Findings Include:

During the building inspection on July 11, 2017at 11:20 AM, observation revealed holes in the ceiling and walls of the Boiler Room and Soiled Linen Room of the facility. The Boiler Room and Soiled Linen Room were incapable of resisting the passage of smoke.

Based on document review, the facility failed to properly maintain the kitchen hood suppression system as addressed by NFPA 96 section 11.5. This standard deficiency practice affected entire facility on the day survey.

Findings include:

On July 11, 2017 at 11:40 am, the maintenance person could not provide documentation of the last two (2) inspections of the kitchen suppression system. The kitchen suppression system must be inspected every six (6) months. The last inspection of the kitchen suppression system was dated November 2016.

Based on record review, the facility failed to provide and properly maintained fire alarm system as required by NFPA 72 Table 14.3.1. This standard deficiency practice affected entire facility on the day survey.

Findings Include:

On July 11, 2017 at 11:35 am, the maintenance person could not produce documentation of an annual inspection or sensitivity testing of the fire alarm system being performed in the last year.

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building as required by NFPA 101 section 19.3.5.1. This standard deficiency practice affected entire facility on the day survey.

Findings include:

On July 11, 2017 at 11:10 am, observation revealed the storage shed, attached to the rear loading dock of the facility, was not protected by automatic sprinkler system. The storage shed was made up combustible, wood material.

Based on observations, the facility failed to ensure proper supervisory signals in accordance with NFPA 101 section 9.7.2.1 and NFPA 72. This standard deficiency practice affected entire facility on the day survey.

Findings include:

On July 11, 2017 at 11:00 AM, observation revealed the post indicator valve that turned off the water supply to the fire sprinkler system was not supervised by a tamper switch. The tamper switch would then send a supervisory signal to a continued supervised area of the facility.

Based on observations, the facility failed to inspect install fire extinguishers as required by NFPA 10 sections 7.2.1.1 and 7.3.1.2.1. This standard deficiency practice affected entire facility on the day survey.

Findings Include:

On July 11, 2017 between 10:00 AM and 2:00 PM, observation revealed the facility was not performing monthly inspections of the all fire extinguishers in the facility. It was also observed the K-class fire extinguisher in the kitchen of the facility was overdue for a six (6) year inspection and was last inspected in the year 2006.

Based on observations, the facility failed to properly protect corridors as per NFPA 101 section 19.3.6.1. This standard deficiency practice affected entire facility on the day survey.

Findings include:

On July 11, 2017 at between 10:00 AM and 2:00 PM, observation revealed unsealed holes in the corridor wall of the following room locations in the facility:

1) Ante Room for Room 211,
2) East Nursing Supply Room
3) Mop Room
4) Computer Room near the Front Entrance

Based on observation, the facility failed to properly protect corridor openings as directed by NFPA 101 sections 19 3.6.3.1 and 19.3.6.3.5. This standard deficiency practice affected entire facility on the day survey.

Findings Include:

On July 11, 2017 between 11:00 AM and 2:00 PM, observation revealed the corridor door deficiencies in the areas of the facility:

1. Corridor doors to DON's Office, Room 205 and Room 213 contain unsealed holes and could not resist the transfer of smoke through the facility.
2. Corridor doors to Recovery Room, Room 104, and Room 106 lacked positive latching and could not resist the transfer of smoke through the facility.
3. Corridor doors to the Pharmacy and Little Central lacked positive latching on the top leaf of the door.

section 19.3.6.4.1. This standard deficiency practice affected entire facility on the day survey.


Findings include:

On July 11, 2017 at 10:55 AM, observation revealed air transfer grilles in the following corridor door of the facility:

1. East Ice Machine Room
2. East Clean Linen Room
These corridor doors were unable to resist and limit the transfer of smoke throughout the facility.

Based on observations, the facility failed to properly provide smoke barrier walls for the purpose of providing one half hour fire resistance in accordance NFPA 101 section 19.3.7.3. This standard deficiency practice affected entire facility on the day survey.


Findings Include:

On July 11, 2017 at 1:30 PM, observation revealed all three (3) smoke barrier walls in the facility did not properly extend to the roof deck of the facility. The three (3) smoke barrier walls terminated at the old plaster ceiling but the ceiling was no longer intact and solid. The old plaster ceilings contain unsealed holes.

Based on observations and testing, the facility failed to properly maintain door openings in smoke barrier walls as per NFPA 101 sections 19.3.7.8 and 19.2.2.2.7. This standard deficiency practice affected entire facility on the day survey.

Findings Include:

On July 11, 2017, at 1:20 PM, observation revealed the magnetic locks on all three (3) smoke barrier doors in the facility would re-energize and lock when the fire alarm system was silenced mode. The magnetic locks, on all three (3) smoke barrier doors, should not have re-engaged to hold the doors in the open position. The fire alarm system was still initiated, therefore the magnets locks on all three (3) smoke barrier doors shall be in the demagnetize position.

Based on observations, the facility failed to properly protect the entire generator's required components as required by NFPA 99 section 6.4.1.1.17. This standard deficiency practice affected entire facility on the day survey.

Findings include:

On July 11, 2017 at 12:28 PM, observation revealed no hard wired, remote annunciator panel for generator at a constantly monitored location (ex. nursing station, or etc ....) in the facility.

Based on observation (testing and document review), the facility did not maintain the generator in accordance to NFPA 99 section 6.4.4 and NFPA 110 section 8.4.2. This standard deficiency practice affected entire facility on the day survey.


Findings include:

On July 11, 2017 at 12:25 PM, observation revealed the temporarily installed generator would not crank and transfer power to the facility within the allotted 10 seconds. Observation (at 12:25 PM) also revealed the generator was found to be in warning alarm status. At 12:45 PM, another attempt was made to restart the generator but the generator failed to crank. A generator service company was called by the maintenance director and a generator technician was able to repair the generator allowing power to be transferred to the facility. The generator technician brought a backup generator to the facility in case of a power failure to the facility.

On July 11, 2017 at 11:35 AM, the facility could not provide documentation of monthly load test performed on the generator in the last year at the facility. The monthly load test shall be performed at least the required 30 minutes.