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Based upon observations made in the presence of the facility director on 09-07-2021, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5(18.3.2.1)

This deficiency affected 1 of several smoke compartments

Findings include:
1- During the facility tour it was observed that in the dietary storage room door was propped open. Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

Based upon observations made in the presence of the facility director on 09-07-2021, it was determined that the facility did not provide a fire sprinkler system in accordance with NFPA 101 19.3.5, 9.7

This deficiency affected 1 of several fire sprinklers.

Findings include:
During the tour of the facility it was observed that there was no fire sprinkler's protection in the EVS mop closet across from the pharmacy. Nursing homes are to be sprinkled throughout in accordance with NFPA 101 19.3.5, NFPA 13 8.1.

Based upon observations made in the presence of the facility director on 09-07-2021, it was determined that the facility did not maintain the smoke barriers to provide at least a one-half hour fire resistance rating in accordance with NFPA 101 19.3.7.

The deficiency affected 6 of several smoke compartments

Findings include:
1-During the tour of the facility it was observed that the fire/smoke barrier wall above the double corridor doors from the lobby to the clinical areas had penetrations in the rated wall. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating in accordance with NFPA 101 19.3.7.3.
2- During the tour of the facility it was observed that the fire/smoke barrier wall above the double corridor doors to the medical surgical areas had penetrations in the rated wall. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating in accordance with NFPA 101 19.3.7.3.
3- During the tour of the facility it was observed that the fire/smoke barrier wall above the double corridor doors to the Emergency Room areas had penetrations in the rated wall. Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating in accordance with NFPA 101 19.3.7.3.

Based on observations made in the presence of the facility director on 09-07-2021 it was that the facility did not maintain ground fault circuit interrupters (GFCI) in accordance with NFPA 101 19.5.1 and 9.1.2, NFPA 99 6.3.2.2.6.2 (F)

This deficiency affected 2 of several GFIC protected outlets.

Findings include:
1-During the facility tour the outlet in the boiler room at the hand wash sink was observed to be within 6ft of the sink and not GFCI protected. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2- During the facility tour the outlet in the medical surgical nutrition area hand wash sink was observed to be within 6ft of the sink and not GFCI protected. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)

Based upon observations made in the presence of the facility director on 09-07-2021, it was determined that the facility did not use plug stripes and or extension cords in accordance with NFPA 101, 99 and 70.

This deficiency affected 1 of several smoke compartments.

Findings include:
1-During the facility tour it was observed that a power strip was plugged into another power strip in the respiratory therapy room. The power strips were removed at the time of the tour. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 70 110-3b

Based upon observations made in the presence of the facility director on 09-07-2021, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 101 19.3.2.4.

This deficiency affected 1 of several H cylinders in the facility.

Findings include
During the facility tour an H cylinder nitrogen was observed in the boiler room medical gas storage room that was not secured and not in accordance with NFPA 19.3.2.4 and NFPA 99 4-3.1.1.8 (a)