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Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.3, 8.5.6.5 and 8.5.6.2.

Findings include:

On 04/16/2024, between 0800am and 12:00pm, it was revealed by observation that there was a penetration running from one smoke compartment to another above door U1 in main corridor and door CT9 in main corridor.

An interview with the Director of EVS and Director of Plant Operations verified these deficient findings at the time of discovery.

Based on observation, a review of available documentation, and staff interview, the facility failed to install the required safety features for cooking equipment per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.5.3 (9) and 19.3.2.5.4.

Findings include:

On 04/16/2024, between 0800am and 12:00pm, it was revealed by observation that the residential stove located in physical therapy was not equipped with a lock-out switch and was not on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cook-top or range, independent of staff action.

An interview with the Director of EVS and Director of Plant Operations verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to maintain the fire alarm system per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.3, and NFPA 72 (2010 edition), National Fire Alarm and Signaling Code section 14.2.1.2.2.

Findings include:

On 04/16/2024, between 0800am and 12:00pm, it was revealed by a review of available documentation that the annual fire alarm inspection report dated 09/20/20204 that the facility provided at the time of the survey, there was no indication that the sensitivity testing had been completed.

An interview with the Director of EVS and Director of Plant Operations verified these deficient findings at the time of discovery.

Based on a review of the available documentation and staff interview, the facility failed to implement a fire evacuation plan per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.6.

Findings include:

On 04/16/2024, between 0800am and 12:00pm, it was revealed by a review of available documentation that the facility could not provide a copy of an Out of Service Policy indicating that the facility would contact the State Fire Marshals Office (Authority having jurisdiction) in the event on a fire alarm outage lasting longer than four (4) hours in a 24-hour period.

An interview with the Director of EVS and Director of Plant Operations verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9.

Findings include:

On 04/16/2024, between 0800am and 12:00pm, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in room S124.

An interview with the Director of EVS and Director of Plant Operations verified these deficient findings at the time of discovery.

Based on document review and staff interview, the facility did not properly implement a fire watch protocol for when the fire alarm system is out of service for more than 10 hours in a 24-hour period, according to NFPA 101 2012 edition, Life Safety Code, section 19.3.5.1, 9.7.5, and NFPA 25 2017 edition, Installation, Test and Maintenance of Water Based System, section 15.5.2.

Findings include:

On 04/16/2024, between 0800am and 12:00pm, it was revealed by documentation review that the facility failed to provide an out of service policy that indicated that the facility would contact the State Fire Marshals Office (Authority having jurisdiction) in the event on a fire sprinkler system outage lasting longer than ten (10) hours in a 24-hour period. .

An interview with the Director of EVS and Director of Plant Operations verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1.

Findings include:

On 04/16/2024, between 0800am and 12:00pm, it was revealed by observation that the following fire doors and/or fire door frames were missing door rating tags - Fire doors L4

An interview with the Director of EVS and Director of Plant Operations verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the electrical system per NFPA 101 (2012 edition), Life Safety Code, section 9.1.2, and NFPA 70 (2011 edition), National Electrical Code, section 406.6.

Findings include:

On 04/16/2024, between 0800am and 12:00pm, it was revealed by observation that there was a missing cover on an electrical junction box in wall located in storage room S124.

An interview with the Director of EVS and Director of Plant Operations verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363.

Findings include:

On 04/16/2024, between 0800am and 12:00pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in office areas in proximity to patient care areas:

1) Access Office - Daisy Chained Appliances
2) Office 234 - Extension Cord / Daisy Chained appliances
3) Office 233 - Extension Cord
4) Imaging Directors Office
5) IT Room - Power Strip
6) COO Office - Extension Cord / Daisy Chained appliances

An interview with the Director of EVS and Director of Plant Operations verified these deficient findings at the time of discovery.