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Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice had the potential to affect 15 of 15 residents.


Findings:

During the facility tour and interview with staff on 11/27-28/2018, between the hours of 8:30a-4:00p observation revealed a dead bolt keyed lock located on the stair exit from the OB suite. Observation also revealed the one of the other exit was equipped with a special locking that did not met the requirements of the code.

When special locking devices are permitted one of three options is required in order to allow free egress for staff and visitors. The three options are:

1. The access code for the keypad is posted at the device, or,
2. The key to the override switch is posted at the device, or,
3. Staff carry a key to the override switch at all times

Observation also revealed corridor doors on the Therapy hall, 200 hall and lab were equipped with independant dead bolts that do not release with one releasing operation per NFPA 101 7.2.1.5.10.2.

Interview with Administrator revealed the facility was not aware that one of the three options is required in order to exit from the building or deadbolts were installed on doors requiring multiple releasing operations.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 15 of 15 residents.


Findings:

During the facility tour on 11/27-28/2018, between the hours of 8:30a-4:00p observation revealed rooms 204, 202, 201, 203, room by 203, 217 and Outpatient rehab storage. These rooms greater that 50 square feet in size were being used for storage without proper protection or separation.

Interview with Administration revealed the facility was not aware that these rooms used for storage were not properly protected.

Based on visual observation and record review the facility failed to assure that routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 15 of 15 residents.

Findings:

During the facility tour and record review on 11/27-28/2018, between the hours of 8:30a-4:00p observation revealed build up of grease on the hood system and surrounding area. System was last cleaned in 2017.

Interview with Administrator revealed the facility was not aware the required cleaning had not been conducted on the hood system.

Based on visual observation the facility failed to assure that parts of the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 15 of 15 residents.

Findings:

During the facility tour on 11/27-28/2018, between the hours of 8:30a-4:00p observation revealed no sprinkler protection in the IT equipment room located by the Hope Unit.

Interview with Administrator revealed the facility was not aware the automatic sprinkler system was not complete.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 15 of 15 residents.

Findings:

During the facility tour on 11/27-28/2018, between the hours of 8:30a-4:00p observation revealed unsealed penetration in the front lobby, 100 hall barrier in Hope Unit, pipe chase in stairwell of Hope Unit, Endo entrance door, barrier @ ICU and barrier of 1st floor crossover.

Interview with Administrator revealed the facility was not aware of unsealed penetration.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect 15 of 15 residents.

Findings:

During the facility tour on 11/27-28/2018, between the hours of 8:30a-4:00p observation revealed open junction boxes located above the ceiling in laundry, outside housekeeping break room and several locations throughout the facility.

Interview with Administrator revealed the facility was not aware of the open junction boxes throughout the facility.