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Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs.


Findings:

During the facility tour and interview with staff, between the hours of 8:45am and 6:00pm the following was observed:

1)The ER exam room 1 had a double sided key lock.
2) The on-call doctor sleeping room exit door had the door lock broke making the door inoperable.
3) Multiple doors in the mechanical area had hasps, pad locks, and broke door hardware.

Interview with the CEO revealed the facility was not aware that exits were being locked or obstructed.

Based on visual observation the facility failed to assure that all doors in the means of egress provided sufficiate exiting for the occupant load. NFPA 101:19.2.2.2.10.2 states, "Horizontal-sliding doors serving an occupant load of fewer than 10 shall be permitted."


Findings:

During the facility tour, between the hours of 8:45am to 6:00pm it was observed that a horizontal-sliding door had been installed in the corridor on the first floor leading to the administration area.

Interview with the CEO revealed the facility was not aware that horizontal-sliding door was not permitted.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 18 of 18 residents.

Findings:

During the facility tour and the record review, between the hours of 8:45am and 6:00pm the following was observed:

1) The smoke detectors had not been provided with and/or documented smoke sensitivity test in over two years.
2) The HVAC Dampers have not been provided with and/or documented as being tested at the required intervals.

Interview with the CEO revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 6 of 18 residents.
3 of 6 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 7:45am to 6:00pm it was observed that the two hour rated wall on the second floor above the double doors was not complete. The fire wall did not extend to the roof deck and to the outside wall or another fire barrier. The two hour wall on the first floor next to x-ray had penetrations and gaps present. The x-ray film area that had a one hour rated smoke/fire barrier had numerous penetrations. This area also had a fire shuttter that had no documentation of the last time it was provided with inspection and service.

Interview with the CEO revealed the facility was not aware of unsealed penetration and gaps in the fire/smoke barriers.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 18 of 18 residents.
3 of 4 quarters in 2018-2019 were deficient.

Findings:

During the record review, between the hours of 8:45am to 6:00pm the following was observed:

1) No drill was performed and/or documented for the 7am-3pm shift on the first quarter of 2019
2) No drill was performed and/or documented for the 11pm - 7am shift on the second quarter of 2019
3) No drill was performed and/or documented for the 3pm -11pm shift on the fourth quarter of 2018

Interview with the CEO revealed the facility was not aware fire drills were not being held for each shift every quarter.

Based on visual observation and record review, the facility failed to assure that Hospital-grade receptacles at patient bed locations are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. The deficient practice had the potential to affect 18 of 18 residents.

Findings:

During the record review, between the hours of 8:45am to 6:00pm it was observed that no testing and/or documentation for the hospital -grade receptacles at patient bed locations was provided.

Interview with the CEO revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the hospital-grade receptacles.

Based on visual observation the facility failed to assure that the generator was provided with a remote annunciator that is storage battery powered to operate outside the generating room in a location readily observed by operating personnel in accordance with NFPA 99. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 18 of 18 residents.

Findings:

During the facility tour, between the hours of 8:45am to 6:00pm it was observed that a remote annunciator was not provided for the generator.


Interview with the CEO revealed the facility was not aware of the requirement of a remote annunciator hard-wired to indicate alarm conditions of the emergency power source.