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Based upon observation and interview the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7 and continuously maintained free of all obstructions to full use in case of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect all occupants on the Ground Floor in the event of a fire.

Findings Include:

1. On 4/15/19 at approximately 11:59 am, the following observation was made with a confirmation interview:

a. During an inspection of the Ground Floor, the exit discharge doors adjacent to the Maintenance Office were observed to be equipped with a slide-bolt type lock assembly at the top of the inactive leaf . This was confirmed at time of observation by the Facility's Coordinator.

Based upon observation and interview the facility failed to ensure that stairways and smokeproof enclosures used as exits are in accordance with 7.2 as required by 19.2.2.3 and 19.2.2.4.7.2. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

1. On 4/15/19 at approximately 11:49 am, the following observation was made with a confirmation interview:

a. During an inspection of the Ground Floor, Stairwell 6 Basement door G-055 was observed not to self-close to a positive latch. This was confirmed at time of observation by the Facility's Coordinator.

Based upon observation and interview the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating as required by 19.3.2.1. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

1. On 4/15/19 at approximately 11:11 am, the following observation was made with a confirmation interview:

a. During an inspection of fire-rated walls on the Ground Floor, the Boiler Room was observed to have an unsealed penetration around an approximately 1' metal conduit penetrating the 2-hour rated wall next to the Vacuum Pump station. This deficient practice could affect all occupants on the Ground Floor in the event of a fire. This was confirmed at time of observation by the Facility's Coordinator.

2. On 4/15/19 at approximately 1:45 pm, the following observation was made with a confirmation interview:

a. During an inspection of the 2nd Floor, Soiled Utility Room 2-018 was observed to have two doors, one on each side of the room, which discharge into the corridor. Both doors have had repairs to one or more hinges on each door which has resulted in damage to the exterior skin on both sides of each door. This deficient practice could affect all occupants on the 2nd Floor in the event of a fire in this room. This was confirmed at time of observation by the Facility's Coordinator.

3. On 4/15/19 at approximately 1:50 pm, the following observation was made with a confirmation interview:

a. During an above ceiling inspection on the 2nd Floor, the Hazardous Storage Room was observed to have an unsealed penetration around a sprinkler pipe penetrating the 1-hour fire rated wall on the left side of the room upon entry. This deficient practice could affect all occupants on the 2nd Floor in the event of a fire. This was confirmed at time of observation by the Facility's Coordinator.

Based upon record review and interview, the facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72 and records were readily available as required by 19.3.4.1, 9.6.1.5, NFPA 70, and NFPA 72. This deficient practice could affect all occupants in the event of a fire.

Findings Include:
1. On 4/15/19 between approximately 2:15 pm and 3:30 pm, during a review of records, it was revealed that there was no documentation of a smoke detector sensitivity test conducted within the past two years. This was confirmed at time of discovery by the Facility's Coordinator.

Based upon records review and interview, the facility failed to ensure that when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction (AHJ) has been notified, and all unprotected areas of the building have been evacuated or an approved fire watch is provided until the system is restored as required by 9.6.1.6. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

1. On 4/15/19 between approximately 2:15 pm and 3:30 pm, during a review of records, it was revealed the facility has a policy that does require a fire watch should the fire alarm system be out of service for more than four hours. Their policy follows the Bureau of Fire Services fire watch policy which is applicable to all state regulated facilities. However, the Center's for Medicare and Medicaid (CMS) policy is more stringent in that it requires a dedicated staff member shall be assigned to no other duties than conducting rounds in the facility and that rounds shall be continual and not hourly as required in the state policy.

The facility's fire watch policy contained within the emergency plan does not address the requirements that persons assigned to fire watch duties not be assigned any other duties nor that fire watch rounds shall be continuous. This was confirmed in an interview by the Facility's Coordinator at time of discovery.

Based upon observation and interview the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect all occupants on the Ground Floor in the event of a fire.

Findings Include:

1. On 4/15/19 at approximately 11:02 am, the following observation was made with a confirmation interview:

a. During an above ceiling inspection on the Ground Floor, the Equipment Room, off the Community Room, was observed to have a flexible metal conduit attached to the fire sprinkler piping by a plastic zip-tie. This was confirmed at time of observation by the Facility's Coordinator.

Based upon records review and interview, the facility failed to ensure that when the sprinkler system is out of service for more than 10 hours in a 24-hour period, the affected areas are evacuated or an approved fire watch is provided until the sprinkler system is returned to service as required by 19.3.5.1 and 9.7.5 of the LSC and 15.5.2 of NFPA 25. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

1. On 4/15/19 between approximately 2:15 pm and 3:30 pm, the following observation was made with a confirmation interview:

a. During a review of records, it was revealed the facility has a policy that does require a fire watch should the fire sprinkler system be out of service for more than ten hours. Their policy follows the Bureau of Fire Services fire watch policy which is applicable to all state regulated facilities. However, the Center's for Medicare and Medicaid (CMS) policy is more stringent in that it requires a dedicated staff member shall be assigned to no other duties than conducting rounds in the facility and that rounds shall be continual and not hourly as required in the state policy.

The facility's fire watch policy contained within the emergency plan does not address the requirements that persons assigned to fire watch duties not be assigned any other duties nor that fire watch rounds shall be continuous. This was confirmed by the Facility's Coordinator at time of discovery.

Based upon observation and interview the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect all occupants on the 2nd Floor in the event of a fire.

Findings Include:

1. On 4/15/19 at approximately 1:34 pm, the following observation was made with a confirmation interview:

a. During an inspection of corridor doors on the 2nd Floor, Housekeeping Room 2-076 door frame was observed to have a missing strike plate. This condition prevented the door from being secured when closed. This was confirmed at time of observation by the Facility's Coordinator.

Based upon observation and interview the facility failed to ensure that suspended unit heaters met the requirements of 19.5.2.3(1). This deficient practice could affect all occupants in the roof top Mechanical Penthouse due to exposed electrical wiring.

Findings Include:

1. On 4/15/19 at approximately 1:38 pm, the following observation was made with a confirmation interview:

a. During an inspection of the roof top Mechanical Penthouse, a suspended unit heater, near the center of this area, was observed to have exposed electrical wires directly behind the unit fan. This was confirmed at time of observation by the Facility's Coordinator.

Based upon observation and interview the facility failed to ensure that power strips are listed for the area in which they are used as required by 10.2.3.6 of NFPA 99 and 400-8 of NFPA 70, and TIA 12-5 and that extension cords are placed in use only temporarily as required by 10.2.4 of NFPA 99 and 590.3(D) of NFPA 70. This deficient practice could affect all occupants on the Ground Floor in the event the device fails and causes a fire.

Findings Include:

1. On 4/15/19 at approximately 11:25 am, the following observation was made with a confirmation interview:

a. During an inspection of the Ground Floor, Central Storage, near the desk area, was observed to have a microwave plugged into a remote power tap. This was confirmed at time of observation by the Facility's Coordinator.