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Based on observation, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5., 10.2.

Findings include:

1. During an observation on 06/28/2022 at 8:52 a.m., the outside oxygen storage room was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

2. During an observation on 06/28/2022 at 9:07 a.m., the exit door by the clinic was inspected. The door was found to be fitted with a lock which required more than one motion to open the door.

3. . During an observation on 06/28/2022 at 9:08 a.m., the public restroom was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

4. During an observation on 06/28/2022 at 9:11 a.m., the lab was inspected. The door to the room was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

5. During an observation on 06/28/2022 at 9:12 a.m., the X-ray room was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

6. During an observation on 06/28/2022 at 9:33 a.m., the kitchen cooler room was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

7. During an observation on 06/28/2022 at 9:34 a.m., the kitchen door to the maintenance hallway was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

8. During an observation on 06/28/2022 at 9:45 a.m., the beauty shop was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

9. During an observation on 06/28/2022 at 9:51 a.m., the activity room was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

10. During an observation on 06/28/2022 at 10:01 a.m., room 306 was inspected. The door was found to be fitted with a dead-bolt lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

11. During an observation on 06/28/2022 at 10:04 a.m., the physical therapy room was inspected. The door was found to be fitted with a dead-bolt lock which required more than one motion to open the door. The room had the capacity to hold three or more people.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8.

Findings include:

1. During an observation on 6/28/22 at 8:57 a.m., the basement door leading to the stairwell was inspected. The corridor door was exercised and would not close and latch under the power of the self-closure.

2. During an observation on 6/28/22 at 9:03 a.m., the main level door leading to the stairwell was inspected. The corridor door was exercised and would not close and latch under the power of the self-closure.

3. During an observation on 6/28/22 at 9:14 a.m., the server room door was inspected. The corridor door was exercised and would not close and latch under the power of the self-closure.

4. During an observation on 6/28/22 at 9:31 a.m., the staff lounge door was inspected. The corridor door was exercised and would not close and latch under the power of the self-closure.

5. During an observation on 6/28/22 at 9:59 a.m., the storage room one was inspected. The corridor door was exercised and would not close and latch under the power of the self-closure.

Based on observation, the facility failed to prevent the use of an enclosed exit stairway for storage purposes per NFPA 101-2012, Sections 7.1.3.2.3 and 7.2.2.5.3.

Findings include:

1. During an observation on 06/28/22 at 8:56 a.m., the stairwell to the basement was inspected. There were several boxes of ceiling tiles being stored in the stairwell.

Based on observation, the facility failed to ensure all exit signs were totally visible in accordance with NFPA 101 2012 Edition, Section 7.10.1.8.

Findings include:

1. During an observation on 06/28/2022 at 9:50 a.m., the activity room was inspected. There was an exit egress door in the room with a manual pull station located directly next to the door. During the inspection, the surveyor was told the door was used as an emergency exit. The door did not have exit signage above or near the door, indicating the door could be used as an exit during an emergency evacuation.

Based on observation, the facility failed to assure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 06/28/22 at 9:44 a.m., the beauty shop was inspected. The room was observed being used as a storage area, and it is over 50 square feet. There was no self-closing device on the corridor door as required for storage rooms.

Based on observation, the facility failed to maintain all fire suppression systems in accordance with the standards of NFPA 72-2010 Section 10.5.5.2.1-10.5.5.2.4.

Findings include:

1, During an observation on 06/28/2022 at 9:29 a.m., the fire alarm control panel was inspected. The main power circuit panel and breaker were not permanently identified on the FACP. The breaker for the FACP in the circuit panel was not identified in red.

Based on observation, the facility failed to ensure accessibility to a manual fire alarm box in accordance with NFPA 101, 2012 Edition, Section 9.6.2.7


Findings include:

1. During an observation on 06/28/22 at 9:40 a.m., the fire alarm pull station located in the main entrance was observed blocked from easy access by a sofa being stored in front of it.

2. During an observation on 06/28/22 at 9:50 a.m., the fire alarm pull station located in the activity room was observed blocked from easy access by a recliner being stored in front of it.

3. During an observation on 06/28/22 at 9:58 a.m., the fire alarm pull station located in the 200 hall was observed blocked from easy access by a hoyer lift being stored in front of it.

4. During an observation on 06/28/22 at 10:03 a.m., the fire alarm pull station located in the 300 hall entrance was observed blocked from easy access by a chair and a garbage can being stored in front of it.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings Include:

1. During an observation on 06/28/2022 at 9:47 a.m., the shower room bath in the 200 hall was inspected. A ceiling mounted light fixture was observed, obstructing a sprinkler head within the room. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

2. During an observation on 06/28/2022 at 9:49 a.m., the shower room in the 200 hall was inspected. A ceiling mounted light fixture was observed, obstructing a sprinkler head within the room. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

Based on observation, the facility failed to:

a) maintain automatic fire sprinklers in reliable operating condition including examination of the heads per NFPA 25-2011, Sections 5.2.1.1.2;
b)ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3);
c) Maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5;
d)ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.;
e) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.

Findings include:

1. During an observation on 06/28/2022 at 9:00 a.m., the basement was inspected. The sprinkler head in the room was observed, its escutcheon ring was pulling away from the ceiling.

2. During an observation on 06/28/2022 at 9:10 a.m., the lab was inspected. There was a ceiling tile with a large hole in it, this could hamper or defeat the proper activation of the sprinkler system should a fire start in the room.

3. During an observation on 06/28/2022 at 9:14 a.m., the clinic hallway was inspected. Three ceiling tiles were noted with holes in them, this could hamper or defeat the proper activation of the sprinkler system should a fire start in the area.

4. During an observation on 06/28/2022 at 9:19 a.m., the sprinkler spare box was inspected. There were several areas noted throughout the facility to have quick response sprinkler heads, but there were none observed in the spare sprinkler box.

5. During an observation on 06/28/2022 at 9:24 a.m., the main entrance was inspected. A ceiling tile was observed missing from the ceiling structure, this could hamper or defeat the proper activation of the sprinkler system should a fire start in the area.

6. During an observation on 06/28/2022 at 9:30 a.m., the hallway outside the maintenance office was inspected. Two holes were observed in the ceiling tiles, this could hamper or defeat the proper activation of the sprinkler system should a fire start in the area.

7. During an observation on 06/28/2022 at 9:32 a.m., the kitchen cooler room was inspected. A rolling pin was observed stored within 18 inches of the sprinkler head within the room.

8. During an observation on 06/28/2022 at 9:35 a.m., the kitchen was inspected. Two sprinkler heads within the room were observed, loaded with dust and debris.

9. During an observation on 06/28/2022 at 9:43 a.m., the main entrance was inspected. The sprinkler head in the room was observed, its escutcheon ring was pulling away from the ceiling.

10. During an observation on 06/28/2022 at 9:49 a.m., the nursing station was inspected. There was a ceiling tile with a large hole in it, this could hamper or defeat the proper activation of the sprinkler system should a fire start in the room.

11. During an observation on 06/28/2022 at 9:57 a.m., the hallway outside of room 209 was inspected. There was a ceiling tile with a large hole in it, this could hamper or defeat the proper activation of the sprinkler system should a fire start in the room.

12. During an observation on 06/28/2022 at 10:08 a.m., the upstairs air handler room 1 and 2 was inspected. There multiple cords found to be attached to the sprinkler pipe in the room.

Based on observation, the facility failed to:

a) maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.; and
b) inspect portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2.

Findings include:

1. During an observation on 06/28/2022 at 8:58 a.m., the fire extinguisher by the basement stairway was inspected. There was a portable fire extinguisher mounted on the wall that was observed obstructed by a chair and a box being stored in front of it.

2. During an observation on 06/28/2022 at 9:47 a.m., the nursing station was inspected. The portable fire extinguisher was found to be missing a monthly maintenance check for May 2022.

Based on observation, the facility failed to ensure smoke barriers were maintained to prevent the potential for smoke to spread in accordance with NFPA 101-2012, Section 19.3.7.3. This deficiency affects 1 of 5 smoke compartments.

Findings include:

1. During an observation on 06/28/2022 at 9:17 a.m., the fire compressor room was inspected. Four pipes within the room were found to have unsealed penetrations around them.

2. During an observation on 06/28/2022 at 9:26 a.m., the maintenance office was inspected. Unsealed penetrations were noted in several areas along the wall.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6.

Findings include:

1. Review of facility documents regarding fire drills for the last year reflected there was no documentation for a completed drill for:

-AM shift for the 2nd quarter of 2021;
-PM shift for the 3rd quarter of 2021;
-NOC shift for the 1st quarter of 2022.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

Findings include:

1. Review of the fire safety maintenance records on 06/28/2022, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

Based on observations, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 06/28/2022 at 9:27 a.m., the maintenance office was inspected. Six large electrical panels were blocked from easy access by several items being stored in front of them.

Based on record review, the facility failed to maintain the receptacles in patient areas. The deficient practice affected the entire facility.

Findings include:

Record review on 06/28/2022 revealed non-hospital grade receptacles located in resident rooms throughout the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation, the facility failed to ensure an emergency stop button for the generator was installed in accordance with NFPA 110, 2010 Edition, Section 5.6.5.6.

Findings include:

1. During an observation on 06/28/2022 at 8:54 a.m., the generator was inspected. The generator providing power for emergency power did not have a remote manual stop outside of the housing of the prime mover or elsewhere on the premises.

Based on observation, the facility failed to ensure extension cords were not used in the facility per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4;

Findings include:

1. During an observation on 06/28/22 at 8:59 a.m., the basement was inspected. Several extension cords were observed, daisy chained to one another and plugged into the outlet within the room, powering the COVID trailer which was parked in the driveway outside the facility.

2. During an observation on 06/28/2022 at 9:25 a.m., the maintenance office was inspected. A white extension cord was found in use, plugged into an electric outlet on the wall.

Based on observations, the facility failed to ensure that:
a) the oxygen storage locations were maintained in accordance with NFPA 99-2012 Edition, Sections 11.3.2.1, 11.3.2.2.; and
b) medical gas storage and administration was performed safely.

Findings include:

1. During an observation on 06/28/2022 at 8:52 a.m., the outside oxygen storage room was inspected. The oxygen storage room was located outdoors and lacked a cautionary oxygen sign on the door of the room. Signage must include the following wording as a minimum:

CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

2. During an observation on 06/28/2022 at 9:55 a.m., a compressed gas cylinder within the oxygen room was unsecured, lying on top of other oxygen cylinders, and could fall creating a hazard.