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Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 4 of 4 residents.

Findings:

During the facility tour on 4/11/2018 between the hours of 8:00 am to 4:30 pm it was observed the main fire alarm is lacking a properly completed sensitivity test by a licensed fire alarm agent.

Interview with the Administrator revealed the facility was not aware that the required inspection had not been conducted on the fire alarm system.

Based on visual observation the facility failed to provide properly door frame latching corridor doors for the residents sleeping rooms as per NFPA 101:3.6.3.5. When the inpatient bedroom doors latch a smoke resistive seal is formed to protect the room's occupants. The deficient practice had the potential to affect 0 of 4 residents involving 1 of 2 corridors having sleeping room doors that were deficient.

Findings:

During the facility tour on 4/11/2018 between the hours of 8:00 am to 4:30 pm, observations noted resident sleeping room 12 was not fully latching properly. NFPA 101:3.6.3.5 (1) states "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"(lbf / pound - force).

Interview with Administrator revealed the facility was not aware of the corridor door to Room 12 was not latching in the frame

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 0 of 4 residents.

Findings:

During the facility tour on 4/11/2018 between the hours of 8:00 am to 4:30 pm it was observed the sprinkler riser room electrical wiring tied into the sprinkler pipe heat trace freeze protection does not appear to be properly wired in accordance with the standards of the NEC. In addition, the following locations had exposed wires: the hot water heater room junction box cover is missing, the eastern most HVAC room HVAC unit junction box cover is missing, the patient room 13 electrical outlet is missing a electrical cover, the patient room 11 surface mounted electrical conduit is damaged and patient room 12 & 13 electrical wiring is exposed outside the proper electrical conduit.

Interview with the Administrator revealed the facility was not aware of the open junction boxes, exposed wires, etc.

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 4 of 4 residents.
3 of 3 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour on 4/11/2018 between the hours of 8:00 am to 4:30 pm it was observed all three corridors were using the corridor as return air plenum for all adjoining rooms.

Interview with the Administrator revealed the facility was not aware the HVAC system was using the corridors as a return air plenum. A waiver has been applied for by the administrator.

Based on visual observation and documentation, the facility failed to provide draperies that are resistant to a heat source, which includes, cigarette ignition (smoldering). When the right materials are used it reduces or eliminates the potential of fire and/or smoke emergency. This deficiency could potentially affect 0 of 0 residents.

Findings:

During the facility tour on 4/11/2018 between the hours of 8:00 am to 4:30 pm it was observed the inpatient bedroom 12 and 13 have non flame retardant draperies that exceed the min. 48 sq. ft. per in patient bedroom limitation.

Interview with the Administrator revealed the facility was aware the draperies were not manufactured from fire retardant material.

Based on visual observation the facility is lacking a generator remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard wired to indicate alarm conditions of the emergency power source. A centralized compute system (e. g., building information system) is not to be substituted for the alarm annunciator. NFPA 110:5.6.5.2 (4) A individual alarm indicator to annunciate any of the conditions listed in Table 5.6.5.2. The deficiency has the potential to affect 4 of 4 residents.


During the facility tour on 4/11/2018 between the hours of 8:00 am to 4:30 pm it was observed this facility is lacking a remote generator annunciator in a constantly attended location such as the nurses station.

Interview with the Administrator revealed the facility was not aware a remotely located generator annunciator is required.

Based on visual observation the facility failed to assure that the generator or other alternate power source is capable of manually stop to prevent inadvertent operation. Generator sets are inspected weekly and a monthly testing program on the emergency generator must be conducted a min. of 12 times a year under load for a min. of 30 minutes. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 4 of 4 residents.
12 of 12 months were deficient.

Findings:

During the record review on 4/11/2018 between the hours of 8:00 am to 4:30 pm it was observed the generator logs were lacking pertinent information related to the weekly and monthly documentation. Also, a remote manual stop and properly labeled sisgnage is not provided outside the weatherproof enclosure prime mover housing.

Interview with the Administrator revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator nor was he aware of the required remote manual stop.
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Based on visual observation the facility failed to assure an approved UL 1363 A / UL1363 power strip within the inpatient bedroom patient care vicinity is provided when a power strip is needed. The deficient practice had the potential to affect 0 of 0.

Findings:

During the facility tour on 4/11/2018 between the hours of 8:00 am to 4:30 pm it was inpatient bedroom 13 is using a UL listed power strip to power personal electronic equipment such as the TV.

Interview with the Administrator revealed the facility was not aware that the electrical equipment was improperly protected per CMS memo dated 9/26/2014.