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Based on observations and interview, the facility failed to maintain its doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 7.2.1.5.10-7.2.1.5.10.6 by not ensuring doors in a means of egress shall be readily operable from the egress side. This has the ability to affect one of 20 smoke compartments (2nd floor). The facility had a capacity of 25 with a census of 10 residents at the time of the survey.

Findings include:

Observations and interview on 2/11/20 at 12:27 p.m., revealed door to the Soiled Utility M229 contained a separate dead-bolt lock installed with a positive latching device and in an emergency, someone could be inadvertently locked into this room and would not be able to get out of it.

Maintenance Staff verified this observation during the survey process.

Based on observation, record review and staff interview, the facility failed to provide self-closing devices on doors to hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.2.1.3 and 8.7 and failed to provide separation of hazardous areas from other compartments. These deficient practices would prevent self-closing of doors when released to self-closing action and would not provide required protections of hazardous areas, affecting approximately 10 patients, staff and occupants in one of 20 smoke zones on 2nd Floor. This facility had a capacity of 25 and a census of 10 patients at the time of the survey.

Findings include:

1. Observation on 2/11/20, at 12:22 p.m., revealed the door to Room M202a (Soiled Utility) was not equipped with a self-closing device. Record review of the facility layout showed the deficient practice affected one of 20 smoke zones.

Maintenance Staff confirmed the observations and findings at the time of discovery.

2. Observation of the 2nd Floor Storage Room M207 on 2/11/20 at 12:10 p.m., revealed two small holes in the ceiling and a 1/2 inch penetration surrounding a sprinkler pipe above the door.

Maintenance Staff confirmed these observations during the survey process.

Based on observation and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This could affect patients, staff and visitors in one out of 20 smoke zones in the building (Emergency Room). This facility has a capacity of 25 and a census of 10 residents.

Findings include:

Observation and staff interview on 2/11/20 at 12:32 p.m., revealed the smoke detector located by the desk in the Emergency Communication Center was within one foot from the air supply vent in the ceiling.

Maintenance Staff verified this observation during the survey process.

Based on observation and staff interview, it was determined the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, placing the staff and patients in one of 20 smoke zones at risk in the event of a fire. The facility had a capacity of 25 and a census of 10 at the time of the survey.

Findings Include:

Observation and staff interview on 2/11/20 at 12:41 p.m., revealed the facility failed to provide approved GFCI (Ground Fault Circuit Interrupter) outlet next to the Speciality Clinic water fountain.

Maintenance Staff verified this observation during the survey process.

Based on observation and staff interview, it was determined the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, placing the Staff and Patients in one of 20 smoke zones at risk in the event of a fire. The facility had a capacity of 25 and a census of 10 at the time of the survey.

Findings Include:

Observation and staff interview on 2/11/20 at 12:19 p.m., revealed a refrigerator plugged into a surge protector in the 2nd floor Medication Surgical Nurses' Station.

Maintenance Staff verified these observations during the survey process.