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Based on observation and interview, the facility failed to ensure aisles, passageways, corridors, exit discharges, exit locations and accesses are in accordance with Chapter 7, and continuously maintained free of all obstructions to full use in case of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect 25 out of 41 occupants in the event of a fire emergency.

Findings Include:
On October 31, 2023 at approximately 10:50 AM. observation revealed the facility failed to maintain the exit door #1 located at the end of the hallway at meeting room #1. The door failed to open with less than fifteen pounds of force and was stuck in the frame when tested.

The Area Director of Facilities and Administrator confirmed these findings during interview at the time of observation.

Based on record review and interview, the facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72, and records are readily available as required by 19.6.1.3, 9.6.1.5, NFPA 70 and NFPA 72. This deficient practice could affect 41 out of 41 occupants in the event of a fire emergency.

Findings Include:
On October 31, 2023 at 9:30 AM. record review revealed the facility failed to provide documentation of the required 2 year sensitivity testing on the fire alarms smoke detectors.

The Area Director of Facilities and Administrator confirmed these findings during interview at the time of record review.

Based on record review and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, and records are readily available as required by 9.2.6, 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect 41 out of 41 occupants in the event of a fire emergency.

Findings Include:
On October 31, 2023 at approximately 10:30 AM. record review revealed the facility failed to provide documentation of the required three year internal inspection of the automatic sprinkler system pressurized storage tank.

The Area Director of Facilities and Administrator confirmed these findings during interview at the time of record review.

Based on observation, record review and interview, the facility failed to ensure portable space heating devices shall be prohibited in all health care occupancies. Unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit as required by 18.7.8, 19.7.8. This deficient practice could affect 20 out of 41 occupants in the event of a fire emergency.

Findings Include:
A) On October 31, 2023 at approximately 10:45 AM. observation revealed a portable space heater in office #205, record review revealed the facility has a policy against all portable space heater use.

B) On October 31, 2023 at approximately 10:45 AM. observation revealed a portable space heater in office #218, record review revealed the facility has a policy against all portable space heater use.

C) On October 31, 2023 at approximately 12:05 PM. observation revealed a portable space heater in the Director of Nursing's office, record review revealed the facility has a policy against all portable space heater use.

The Area Director of Facilities and Administrator confirmed these findings during interview at the time of observation and record review.

Based on observation and interview, the facility failed to ensure power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99, 400-8 of NFPA 70 and TIA 12-5, and extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect 5 out of 41 occupants in the event of a fire emergency.

Findings Include:
On October 31, 2023 at approximately 11:20 AM. observation revealed a mini-fridge plugged into a extension cord in the basement maintenance office.

The Area Director of Facilities and Administrator confirmed these findings during interview at the time of observation.