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Based on an observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1 and 19.2.1.

This deficiency affected 1 of 6 smoke compartments in the facility.

Findings include:

1. During an observation on 3/20/24 at 1:25 p.m., The long-term care exit was inspected. There was a wet floor sign and a wheel chair blocking the means of egress and exit door to the public way.

Based on observation, the facility failed to maintain an egress door with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2.

This deficiency affected 1 out of 4 smoke compartments.

Findings include:

During an observation on 3/20/24 at 1:37 p.m., two egress doors from the kitchen had a dead-bolt lock located on the door. The two doors require more then one motion to open the door.

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

This deficiency affects 1 out of 6 smoke compartments at the facility.

Findings include:

During an observation on 3/20/24 at 1:40 p.m., the kitchen storage room door had a rubber stopper fastened to the door. The door was fitted with a self-closure, and would not self-close with the use of the door stopper.

Based on interview and record review, the facility failed to provide emergency lighting per NFPA 101-2012, Sections 19.2.9.1 and 7.9.3.1.1.

This deficiency affects the entire facility.

Findings include:

Review of the facility records for testing of the emergency lighting documentation on 3/20/24, showed the facility had not performed the required 30 second monthly lighting tests for the whole year or the annual 90 minute test.

During an interview on 3/20/24 at 11:06 a.m., staff member B stated he was unaware he needed to complete emergency lighting tests for a certain amount of time. He stated he just made sure they turned on when he tested them.

Based on observation, the facility failed to maintain continuous illumination for all exit signs in accordance with NFPA 101, 2012 Edition, Section 7.10.5.1, and 7.10.5.2.1.

This deficiency affected 1 out of 6 smoke compartments in the facility.

Findings include:

During an observation and interview on 3/20/24 at 1:45 p.m., the rear loading dock exit was inspected. The exit sign was not illuminated. Staff member B stated the exit sign needed a new bulb.

Based record review, the facility failed to maintain the wet chemical extinguishing system for the kitchen hood in accordance with NFPA 17A, 2009 Edition, Section 7.5.1.

This deficiency affects 1 out of 6 smoke compartments in the facility.

Findings include:

Review of the maintenance records on 3/20/24 showed the last hydro test on the main cylinder for the kitchen hood was completed 12/22/2011. The hydrostatic test should have been completed in December of 2023.

Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 14.4.5 (6).

This deficiency affects all smoke compartments at the facility.

Findings include:

During a review of the most recent facility fire alarm inspection on 3/20/24, the fire alarm system was inspected on 6/28/23. There was no indication either written on the batteries or in the panel that the six-month voltage test had been completed by the facility semi-annually.

Based on observation, interview and record review the facility failed:

a) to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2,

b) failed to ensure sprinkler piping was fee from 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, and

c) 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).

These deficiencies affected all smoke compartments in the facility.

Findings include:

1. During an interview on 3/20/24 at 11:08 a.m., staff member B stated the sprinkler inspections were not being completed on a quarterly basis.

Review of the facility's sprinkler inspections on 3/20/24 showed, only one sprinkler inspection was completed in the last year dated 6/22/23. The following quarterly sprinkler inspections were missing:

First quarter of 2023 (January - March 2023)
Third quarter of 2023 (July - September 2023)
Fourth quarter of 2023 (October - December 2023)

2. During an observation on 3/20/24 at 1:03 p.m., the boiler room was inspected. A wire was hanging off the sprinkler piping.

3. During an observation on 3/20/24 at 1:11 p.m., the water closet was inspected. Cords were hanging off the sprinkler piping.

4. During an observation on 3/20/24 at 1:26 p.m. the atrium was inspected. There was a significant gap around the sprinkler piping that was coming out of the wall.

5. During an observation on 3/20/24 at 1:51 p.m., the atrium by the front entrance was inspected. There was a significant gap around the sprinkler piping that was coming out of the wall.

Based on observation, the facility failed to ensure latching fire/smoke barrier doors were maintained per NFPA 101-2012, Section 19.3.7.8., 4.2.3, and 4.6.12.1.

This deficiency affected 2 out of 6 smoke compartments.

Findings include:

During an observation on 3/20/24 at 1:33 p.m., the dinging room double doors were inspected. The fire hardware on the door was not latching after being exercised multiple times.

Based on record review the facility failed to ensure all employees were kept informed with respect to their duties during a fire drill, ensuring competency per NFPA 101. 2012 Edition, section 19.7.1.2., and 19.7.1.6.

This deficiency affects all facility occupants.

Findings include:

Review of the facility fire drills on 3/20/24 showed, the second quarter of 2023 (April - June 2023) did not have staff sign in sheets of who attended, to ensure competency with the fire drill protocol.

Based on observation, interview, and record review the facility failed to inspect, test and document the testing and inspection of fusible link dampers in accordance with NFPA 80, Standard for Fire Door and Other Opening Protectives, 2010 Edition, Section 19.4.1.1

This deficiency affects all smoke compartments in the facility.

Findings include:

During an observation and interview on 3/20/24 at 1:20 p.m., the fusible link damper in the lower level storage room by the crawlspace was inspected. Staff member B stated the facility had multiple fusible link dampers in the facility but he did not know when they were last tested.

Review of the facility's maintenance records did not show a fusible link damper test was completed.

Based on interview and record review, the facility failed to have evidence of the generator weekly visual documentationin accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 2010 Edition, Sections 8.4.1 and 8.4.2.4.

This deficiency affects all smoke compartments.

Findings include:

During an interview on 3/20/24 at 11:05 a.m., staff member B stated he did not have documentation of the weekly visual inspections of the generator, and was not aware he needed to complete, and document a weekly visual inspection.

Record review of the generator information on 3/30/24 did not include any weekly visual documentation of the generator in the last year.