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Tag No.: K0211
Based on observation, the facility failed to properly maintain exit egress as per NFPA 101 section 19.2.1, 7.1.10.1. This standard deficiency affected the entire facility on the day of survey.
Findings include:
On 09/26/22 at 10:55 AM observation revealed the exit egress near Therapy Unit lacked an all-weather surface that led to a public way (sidewalk). The path of exiting the facility from Therapy Unit is not properly accessible (obstruction) to the sidewalk around the facility. Observation also revealed the facility is not protected by fire sprinkler system, so having all exit accessible is important entity evacuating of the facility.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.
Tag No.: K0321
Based on observations, the facility failed to protect hazardous area in accordance with NFPA 101 section 19.3.2.1. This deficient practice had potential of affecting the entire facility on the day of facility survey.
Findings include:
On 09/26/22 at 11:45 AM, observation revealed Rooms 1019 and 1020 were being used to store combustible materials. Rooms 1019 and 1020 were identified as hazardous areas (storage areas) and were incapable of resisting the passage of smoke throughout the facility. Observation also revealed the facility is not protected by fire sprinkler system, so Rooms 1019 and 1020 shall protected with 1 hour fire rated wall and 45-minute fire rated door.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.
Tag No.: K0918
Based on the review of documentation, the facility failed to properly document records of testing the generator annually as directed by NFPA 110 sections 8.4.2.1, 8.4.2, NFPA 99 sections 6.4.4.1.1.3 and 6.4.4.2. This deficient practice had potential of affecting the entire facility on the day of facility survey.
Findings Include:
On 09/26/22 at 10:35 AM, the facility could not produce the documentation for weekly inspections of the generator with the calendar years of 2021 and 2022.
The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 09/26/22.