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Based on observation and staff interview, the facility failed to ensure exit signage was displayed in accordance with NFPA 101 - 2012 Edition, sections 19.2.10.1 and 7.10.1.2.2*. This had the potential to affect all patients receiving services from this facility. The facility census was 281.

Findings include:

Facility tour took place with Staff A, B, C and D from 07/23/19 to 07/24/19. During tour of the volunteer store room, observation was made of no exit signage above the south door to direct persons safely out in the event of an emergency. This finding was verified in an interview with all staff members present during tour.

Based on observation and staff interview, the facility failed to ensure protection of hazardous areas in accordance with NFPA 101 - 2012 Edition 19.3.2, 8.7 and 8.3. This deficient practice had the potential to affect all patients receiving services from the facility. The facility census was 281.

Findings include:

Facility tour took place with Staff A, B, C and D from 07/23/19 to 07/24/19. During tour of the hazardous room identified as CD 107, observation was made above the ceiling tiles of one open end conduit above the door and a duct penetrating the opposite wall that was not sealed around the annular space. This finding was verified in an interview with the staff members during tour of this area.

Based on observation and staff interview, the facility failed to ensure sprinklers and the sprinkler system was properly maintained in accordance with NFPA 101 - 2012 Edition Sections 19.3.5.3 and 9.7.5, and NFPA 25 2011 Edition Section 5.2.1.1.1. This has potential to affect all patients receiving services from the facility. The facility census was 281.

Findings include:

Facility tour took place with Staff A, B, C and D from 07/23/19 to 07/24/19. During tour, observation was made of several sprinkler heads loaded with dust and/or debris in the following locations:

1) within room 194
2) within room 148B
3) within room 130A
4) within room 141
5) within room 151
6) within room 158
7) within the kitchen area of the lower level

This finding was verified in an interview by the staff members present during tour. This was not a comprehensive list of other sprinkler pedants throughout the facility that may contain dust and or debris.

Based on documentation review, observation and staff interview, the facility failed to ensure fire/smoke barriers were maintained in accordance with NFPA 101 - 2012 Edition, Section 19.3.7.3, 8.5.6, and 8.3.5. This deficient practice had the potential to affect patients receiving services from the facility. The facility census was 281.

Findings include:

On 07/23/19 a review of the building schematics revealed the existing smoke/fire barriers had a one and two hour fire resistance rating respectively.

Facility tour took place with Staff A, B, C and D from 07/23/19 to 07/24/19. During tour, observation was made of several areas of the smoke/fire barriers having penetrations that compromised the fire resistance rating. These penetrations were observed above the ceiling tiles in the following locations:

1) Within the corridor near room 133 a cable tray that was not sealed at the top The opening was estimated to be approximately six inches by fourteen inches. This was also observed from within room 194F. The staff members present during tour verified this finding in an interview.

2) Within room 180 and also from the corridor side observation was made of multiple penetrations consisting of an unsealed annular space around a steel beam, open end conduit, holes drilled into the concrete block and unsealed areas at the top of the concrete blocks where it met with the upper deck (the gap was not able to be observed from the vantage point of observation in order to verify if any sealant was applied further back in between the top of the block and the upper deck or roofing).

3) Above the ceiling tiles outside of room 158 observations were made of penetrations around a pipe and blue and white wires, two conduits (one flex and one solid) penetrating the block wall. Within room 158 observation was made of additional penetrations in the block wall, an approximate one and a half inch hole, junction box that lacked a cover plate, open end silver conduit and an unsealed cable tray.

4) Within the nourishment room of pod I-J facing the smoke barrier above the ceiling tiles observation was made of an approximate one and half inch circular hole with a black wire passing through. Additionally, while turning to the right and looking through an opening in the non-fire rated wall into the next room identified as I-120, observation was made of an approximate ten foot by fourteen foot section of drywall missing from the inside portion of the smoke barrier.

5) Within the nourishment room of pod G-H facing the smoke barrier above the ceiling tiles observation was made of an approximate one and half inch circular hole with a black wire passing through. Additionally, observation was made of an approximate three inch by four inch rectangular hole and a open end silver conduit passing through an unsealed square hole in the smoke barrier.

6) Within the nourishment room of pod E-F facing the smoke barrier above the ceiling tiles observation was made of an approximate one and half inch circular hole with a black wire passing through. Additionally, observation was made through an opening in the non-fire rated wall to the right of the smoke barrier into room E120 of a group of silver conduits passing through the smoke barrier that did not have any fire rated sealant in the annular space.

7) Within the corridor of pod C-D at room D101 above the ceiling tiles observation was made of an unsealed silver conduit. Above the door in the nutrition room observation was made of an approximate one and half inch circular hole with a black wire passing through.

8) Within the nourishment room of pod A-B facing the smoke barrier above the ceiling tiles observation was made of an approximate one and half inch circular hole with a black wire passing through. Additionally, observation was made of a silver flex conduit not sealed around the annular space and an opening at the bottom of an square duct passing through the smoke barrier.


These findings were verified in an interview with all staff members present during facility tour.

Based on observation and staff interview, the facility failed to ensure all electrical receptacle outlets near sources of water were equipped with ground fault mechanisms as required by the National Fire Protection Association (NFPA) 101 Chapter 19.1 and NFPA 70 and NFPA 99. This had the potential to affect all patients receiving services from the facility. The facility census at the start of the survey was 281.

Findings include:

Facility tour took place with Staff A, B, C and D from 07/23/19 to 07/24/19. During tour, observation was made of several receptacles that were near sources of water which appeared to not have ground fault mechanisms and were not able to be verified during tour. The locations were as follows:

1) Near the sink in the kitchenette of the medical clinic;
2) In the medication room identified as room #168;
3) Within room M177, five receptacles were observed near a water source; and
4) Within room M179 one receptacle was observed by a water source.

These findings were verified in an interview with all staff present during tour.

Based on observation and staff interview, the facility failed to ensure that remote alarm annunciators for the generators were located in a location readily observed by operating personnel at a regular work station as required by the National Fire Protection Association (NFPA) 99, 2012 edition, 6.4.1.1.17. This had the potential to affect all patients receiving services from this facility. The patient census was 281.

Findings include:

Facility tour took place with Staff A, B, C and D from 07/23/19 to 07/24/19. During tour, observation was made throughout the facility of no remote generator alarm annunciator for any of the three facility generators. This finding was verified by Staff A, B and C during and after tour.