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Based on observation and interview, the facility failed to maintain the self-closing doors. This was evidenced by doors to a hazardous area that were held open by a noncompliant method. This affected the second floor in Building D and could result in the passage of smoke and fire originating from a hazardous area.

NFPA 101 Life Safety Code, 2012 Edition
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to the following:

(7) Rooms or spaces larger than 50 square feet (4.6 square meters), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction

Findings:

During a tour of the facility and interview with staff on 1/31/23, the facility's self-closing doors were observed.

At 2:23 p.m., the General Storage room on the second floor in Building D was observed. The double leaf corridor doors were equipped with self-closing devices and were both held open with door wedges. The room measured approximately 1446 square feet and contained various combustible items. Upon interview, Staff 1 confirmed that the doors were held open with door wedges.

Based on observation and interview, the facility failed to maintain the hazardous area enclosures. This was evidenced by a self-closing door to a hazardous area that failed to fully-close and latch. This affected the first floor in Building D and could result in the passage of a smoke and fire in the event of a fire originating from a hazardous area.

NFPA 101 Life Safety Code, 2012 Edition
19.3.2 Protection from Hazards
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(2) Central/bulk laundries larger than 100 square feet (9.3 square meters)
(5) Rooms with soiled linen in volume exceeding 64 gallons

Findings:

During a tour of the facility and interview with staff on 1/31/23, the facility's hazardous area enclosures were observed.

At 2:00 p.m., the double leaf corridor doors to the Laundry Soiled Area were observed. The doors were equipped with self-closing devices and failed to fully-close and latch when allowed to self-close. The room was approximately 465 square feet. Upon interview, Staff 1 confirmed the finding and stated he had worked on fixing the doors but the pressure in the room and the misaligned latches were preventing the doors from latching properly.

Based on record review and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by deficiencies noted on the annual test and inspection that were not corrected. This affected eight of eight smoke compartments and seven of seven patients and could result in a malfunctioning automatic fire sprinkler system in the event of a fire.

Findings:

During record review and interview with staff on 1/31/23, the facility's automatic fire sprinkler system maintenance records were reviewed and staff was interviewed.

At 4:08 p.m., the facility provided a document titled "Inspection, Testing and Maintenance" that indicated the automatic fire sprinkler system received annual inspection, testing, and maintenance on 5/11/22. The report indicated the following deficiencies:

Riser #A-Newer Bldg. DOES NOT OPERATE
Riser #A-Newer Bldg. Unable to turn PIV shared with buildings D & E
Riser #A-Newer Bldg. Tamper for PIV sets off fire alarms and calls FD
Riser #E-Newer Bldg. Unable to turn PIV shared with buildings A & D
Riser #E-Newer Bldg. Tamper for PIV sets off fire alarms and calls FD
Riser #G-Older Boiler Room-Older Bldg. BELL DOES NOT OPERATE
Riser #G-Older Boiler Room-Older Bldg. Unable to turn PIV shared with Building F
Riser #G-Older Boiler Room-Older Bldg. Tamper for PIV sets off fire alarms and calls FD.
*Backflows do not have hose connections or hydrants connected. Unable to do forward flow test on them.
*Unable to perform full main drain test. Water overflows floor drains and floods out room.
*Tampers set off alarms.

The facility was unable to provide documentation indicating the deficiencies were corrected. Upon interview, Staff 1 confirmed the finding and stated the vendor was scheduled to retest all the main drains the following day and fix any problems. He also stated he had difficulty getting the vendor to return after the annual test to correct the deficiencies.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations through the ceiling. This affected one of four smoke compartments and one of seven patients in Building G and could result in the spread of smoke and fire in the event of a fire.

Findings:

During a tour of the facility and interview with staff on 1/31/23, the integrity of the building construction was observed.

1. At 11:08 a.m., the Administration IT Closet was observed with a penetration through the ceiling. The penetration measured approximately 12 inches by 6 inches and had cables running through it. Upon interview, Staff 1 confirmed the finding and stated the vendors were recently on-site and was not aware they had created the penetration.

2. At 11:28 a.m., the Nurse Scheduling Office was observed with a penetration through the ceiling. The circular penetration measured approximately one inch in diameter. Upon interview, Staff 1 confirmed the finding and stated the room was temporarily used as an office so they installed temporary wiring which may have resulted in the penetration through the ceiling.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch. This affected two of four smoke compartments and one of seven patients in Building G and could result in the spread of smoke and fire in the event of a fire emergency.

NFPA 101 Life Safety Code, 2012 Edition
19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Findings:

During a tour of the facility and interview with staff on 1/31/23, the facility's corridor doors were observed and staff was interviewed.

1. At 10:56 a.m., the corridor door to the Pharmacy Office was observed. The door was equipped with a self-closing device and failed to fully close and latch when allowed to self-close. Upon interview, Staff 1 confirmed that the door did not fully-close and latch.

2. At 11:06 a.m., the corridor door to the Administration Office was observed. The door was equipped with a self-closing device and failed to fully-close and latch when allowed to self-close. Upon interview, Staff 1 confirmed that the door did not fully-close and latch.

3. At 11:35 a.m., the corridor door to the Med Room behind the Nurses Station was observed. The door was equipped with a self-closing device and failed to fully-close and latch when allowed to self-close. Upon interview, Staff 1 confirmed that the door did not fully-close and latch.

4. At 11:39 a.m., the corridor door to the Office behind the Nurses Station was observed. The door was equipped with a self-closing device and failed to fully-close and latch when allowed to self-close. Upon interview, Staff 1 confirmed that the door did not fully-close and latch.

5. At 11:51 a.m., the corridor door to the Respiratory Therapy Receiving Room was observed. The door was equipped with a self-closing device and failed to latch when allowed to self-close. The door was missing the latching mechanism. Upon interview, Staff 1 confirmed that the latch was missing.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the failure to follow manufacturer's recommendations on electrical safety and by the use of extension cords. This affected two of four smoke compartments, one of seven residents in Building G and the first floor of Building D. This could result in the increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services
19.5.1 Utilities
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the
following:
(1) As a substitute for the fixed wiring of a structure

NFPA 99, Health Care Facilities Code, 2012 Edition.
10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart-mounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2) The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4) The electrical and mechanical integrity of the assembly is regularly verified and documented.

Findings:

During a tour of the facility and interview with staff on 1/31/23, the facility's electrical equipment was observed.

Building G
1. At 11:33 a.m., the electrical equipment in the Nurses Station across from Patient Room 1 was observed. A portable space heater was observed under a desk and was plugged into a power strip. The portable space heater was equipped with a fire hazard warning label that indicated the space heater should not be used with power strips or extension cords. Upon interview, Staff 1 confirmed that the portable space heater should not be plugged into a power strip.

2. At 11:56 a.m., the electrical equipment in the Physician's Lounge in the Emergency Room was observed. A red extension cord was used to supply power to a refrigerator. Upon interview, Staff 1 confirmed the finding and stated that staff members were aware that they should not use extension cords.

Building D First Floor
3. At 1:53 p.m., the electrical equipment in the CNA Classroom was observed. A red extension cord was used to supply power to a power strip. The power strip was used for a television and additional electronics. Upon interview, Staff 1 confirmed the finding and stated that staff members have been instructed to not use extension cords and was not sure why it was in use.