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Based on observation and interview, the facility failed to ensure a cooking facility was closed to the corridor in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 19.3.2.5.5, 19.3.2.1.2, 7.2.1.8.1, 7.2.1.8.2 and 8.4.3.5. This had the potential to affect all 21 patients in the facility.

Findings include:

On 04/23/19 at 10:45 A.M. during a tour of the facility with the materials manager, observation was made of the dual-leaf self-closing door system from the first floor main cafeteria was observed in the open position. Further investigation revealed no other self-closing doors were located between the cooking equipment installed in accordance with NFPA 96 and the exit corridor, and neither leaf of dual-leaf self-closing door system separating the first floor main cafeteria from the exit corridor was provided with a hold-open mechanism that released the door upon loss of power.

Interview with the materials manager verified this finding at the time of discovery.

Based on interview and record review, the facility failed to maintain and test fire alarm interfaced equipment in accordance with Edition 2012 of NFPA 101, Life Safety Code, Section 9.6, and Edition 2010 of NFPA 72, Fire Alarm and Signaling, Section 14.2 and Table 14.4.2.2. This had the potential to affect all 21 patients in the facility.

Findings include:

On 04/24/19 at 3:06 P.M., review of monthly fire alarm test result records with the materials manager and director of plant operations, revealed eight of twelve monthly fire alarm test results, including June 2018, July 2018, August 2018, September 2018, December 2018, January 2019, March 2019 and April 2019, did not show the signal was received by the supervising station within 90 seconds of fire alarm actuation.

Interview with the materials manager and director of plant opreations verified this finding at the time of discovery.

Based on observations and interviews the facility failed to ensure all areas open to the corridor were equipped with smoke detectors in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 19.3 and 9.6.1.3, and Edition 2010 of NFPA 72, National Fire Alarm and Signaling Code, Section 17.7.3. This had the potential to affect 11 patients in the smoke compartment and any patients being transferred into or out of the facility. The facility census was 21.

Findings include:

On 04/22/19 at 3:10 P.M., during a tour of the facility with the materials manager, observation was made of the wheelchair alcove adjacent to the lobby receptionist desk was open to the corridor; yet not provided with a smoke detector.

Interview with the materials manager verified this finding at the time of discovery.

Based on record review and interview, the facility failed to ensure the backflow preventer installed on the fire protection water line was tested annually and private fire hydrants were tested and maintained annually in accordance with Edition 2012 of NFPA 101, Life Safety Code, Section 9.7.5, and Edition 2011 of NFPA 25, Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Sections 7.3.2, 7.4.2.1 and 13.6.2.1. This had the potential to affect all 21 patients in the facility.

Findings include:

1. On 04/22/19 at 9:37 A.M., during a review of life safety code documents with the materials manager, the facility failed to provide evidence of annual hydrant testing or maintenance for the fire hydrants connected to the facility's private fire service mains.

Interview with the materials manager verified this finding at the time of discovery; and

2. On 04/24/19 at 9:35 A.M., during a review of sprinkler testing records with the materials manager and the director of plant operations, the facility failed to provide evidence of annual forward flow testing of the water based suppression system backflow preventer. Forward flow testing is required because the facility has hydrants located downstream of the backflow preventer.

Interview with the materials manager and the director of plant operations verified this finding at the time of discovery.

Based on interview and record review, the facility failed to provide a policy that addressed all reporting requirements when the sprinkler system was out of service in accordance with Edition 2012 of NFPA 101, Life Safety Code, Sections 19.3.5, 9.7 and 9.7.6, and Edition 2011 of NFPA 25, Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Sections 15.5.2(6) and 15.6.3. This had the potential to affect all 21 patients in the facility.

Findings include:

On 04/24/19 at 10:39 A.M.a review of the facility's 'Fire Watch Policy' with the chief executive officer, director of plant operations and the materials manager revealed the policy did not address notifying the insurance carrier or other authorities having jurisdiction when the sprinkler system was out of service for more than ten hours in a twenty-four hour period.

Interview with the chief executive officer verified this finding at the time of discovery.

Based on record review and interview, the facility failed to ensure all receptacles at patient bed locations have been tested in accordance with Edition 2012 of NFPA 99, Health Care Facilities, Section 6.3.3.2. This had the potential to affect all 21 patients in the facility.

Findings include:

On 04/24/19 at 12:10 P.M., during a review of the facility's life safety code records with the materials manager and director of plant operations, the facility failed to provide records that all receptacles at patient bed locations had been tested after initial installation for the retention force of the grounding blade.

Interview with the materials manager and director of plant operations verified this finding at the time of discovery.

Based on observation and interview, the facility failed to flexible electrical cords were used in accordance with Edition 2012 of NFPA 99, Health Care Facilities, Sections 10.2.3 and 10.2.4, and Edition 2011 of NFPA 70, National Electrical Code, Section 400.8. This had the potential to affect all 21 patients in the facility.

Findings include:

A. On 04/22/19, during a tour of the facility with the materials manager, the following was observed:

1. At 2:15 P.M., a power strip was attached to the wall in the second floor TBI south equipment storage room;
2. At 2:43 P.M., a power strip, into which communication equipment was plugged, and the flexible power cord for a broadband indoor distribution amplifier, were attached to the wall in the second floor communication room; and
3. At 3:22 P.M., the flexible power cord for a broadband indoor distribution amplifier was attached to the wall in the first floor communication room.
Interview with the material manager verified the above findings at the time of discovery;

B. On 04/25/19 at 10:55 A.M., during a tour of the facility with the chief executive officer and the materials manager, observation was made of a flexible plastic electrical cord with two work lights attached to the building sprinkler system in the central stairwell at the second floor level in the interstitial space above the ceiling tiles. In addition, this flexible cord was run through a hole in the wall.
Interview with the chief operating office verified this finding a the time of discovery; and

C. On 04/25/19 at 1:41 P.M., during a tour of the facility with the chief executive officer, the director of plant operations and the materials manager, observation was made of several flexible plastic electrical cords work lights attached to or draped over the building sprinkler system pipe in the first floor main cafeteria in the interstitial space above the ceiling tiles. In addition, these flexible cords were run through holes in the wall.

Interview with the director of plant operations verified this finding a the time of discovery.