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Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 9 of 9 residents.

Findings:

During the facility tour on 12/1/2021, between the hours of 7:30a-2:00p observation revealed doors to several room converted to storage rooms greater than 50 sq. ft. are not self closing.


Interview with the administrator revealed the facility was not aware that the doors to the hazardous areas were required to self-close and latch in the frame.

Fire doors assemblies are inspected and tested annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not located in required fire barriers, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspection and testing have an understanding of the operating components of the doors. Written records of inspection and testing are maintained and are available for review.18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80)

Based on visual observation the facility failed to ensure the barrier doors were inspected and tested annually in accordance with NFPA 101 and NFPA 80. Barrier doors are an integral part of building separation. When these doors are not functioning properly the risk of a fire/smoke emergency increases.

Finding:

During the facility tour and record review on 12/1/2021, between the hours of 7:30a-2:00p observation and record review revealed door inspections were not being performed or documented.

Interview with the administrator revealed the facility was not aware the barrier doors were not being inspected or documented.

Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)


Based on visual observation, the facility failed to assure receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months in accordance with NFPA 99 6.3.4. The non hospital-grade receptacles are required to be inspected, tested, and documented annually. The deficient practice has the potential to affect of residents.

Findings:
During the facility tour and record review on 12/1/2021, between the hours of 7:30a-2:00p observation and record review revealed the non hospital grade receptacles are not being inspected, tested, and documented as required.

Interview with the administrator revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the non hospital grade receptacles.

Based on visual observation and record review, the facility failed to assure that the weekly inspection and a monthly testing program on the emergency generator was conducted and documented. 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 9 of 9 residents.


Findings:

During the record review on 12/1/2021, between the hours of 7:30a-2:00p record review revealed the weekly inspections and monthly load test are not being performed or documented as required.

Interview with the administrator revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator.