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Based on visual observation the facility failed to assure that sleeping room doors were not equipped with locks that did not require a key to exit. Locks on resident room doors would delay or possibly prevent egress from the building. This deficiency has the potential to affect 6 of 6 residents.

Findings:

During the facility tour, between the hours of 9:00 and 9:30 it was observed that patient room doors had locking hardware and not required passage hardware.

Interview with Maintenance revealed the facility was not aware of the door locks on patient rooms that were not permitted.

Based on visual observation the facility failed to provide the continuation of the exit discharge to include access to the public way from all required exits. The access provides an easier transition for occupants to evacuate from all exits in the building.
The exit discharge was deficient for 1 of 4 exits.

Findings:

During the facility tour, between the hours of 9:00 and 9:30 it was observed that the exit signage located in Physical Therapy room needed to removed and replaced with this is not an exit signage since this exit leads to a courtyard with no exit discharge to a public way.

Interview with Maintenance revealed the facility was not aware that the exit discharge did not continue to the public way.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 6 of 6 residents.

Findings:

During the facility tour and record review, between the hours of 9:00 and 10:00 it was observed that the last annual inspection done on the sprinkler system was dated 7-15-19 and an up to date inspection needed to be completed.

Interview with Maintenance revealed the facility was not aware that the annual and/or quarterly inspections had not been conducted on the automatic sprinkler system and this was also acknowledged by the Administrator during the exit meeting.

Based on visual observation the facility failed to provide doors protecting corridor openings to resist passage of smoke and material capable of resisting fire for at least 20 minutes. Corridor doors to have positive latching hardware.

Findings:

During the facility tour, between the hours of 9:00 and 9:30 it was observed that the following doors were deficient,
1/Patient room door 119 had no door hardware and was not latching
2/Patient room doors 115 and 113 were not latching in their frames
3/Patient room door 111 had holes in door that needed to be sealed

Interview with Maintenance revealed that the facility was not aware that these patient room doors were in need of repair for holes and latching hardware.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 6 of 6 residents.


Findings:

During the facility tour, between the hours of 9:00 and 9:30 it was observed that a penetration of wiring was not sealed above the corridor doors in the smoke barrier.

Interview Maintenance revealed the facility was not aware of the unsealed penetration.

Based on visual observation the facility failed to provide weekly and monthly inspection logs for the weekly running of the generator and the monthly full load testing in accordance with NFPA 110. Written records of maintenance and testing are maintained and readily available.

Findings:

Based on record review and faciility tour, between the hours of 9:00 and 10:30 it was observed that there are no written logs of the maintenance and testing of the generator for the weekly running and the monthly full load testing.
A manual stop button for the generator, located outside of the generator premises is needed in accordance with NFPA110 5.6.5.6 .
Signage to be provided for emergency stop button.

Interview with Maintenance revealed that the facility was not keeping a written log for the testing required in accordance with NFPA 110, and also did not have a emergency stop button for the generator.

Based on visual observation the facility failed to provide working electrical outlets in the laundry building. Extension cords are not used as a subsitute for fixed wiring of a structure in accordance with NFPA 70.

Findings:

During the facility tour, between the hours of 9:00 and 9:30 it was observed that the facility was using extension cords to operate the washer and dryers in the laundry and not being plugged into outlets behind the dryers and washer.

Interview with Maintenance revealed the facility was not aware that the washer and dryers were using extension cords and not plugging them into the outlets on the facility walls