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Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions, in the egress corridor, hinder occupant egress in emergency situations. This deficient practice could potentially affect 3 of 3 residents in the facility.

Findings:

During the facility tour, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was observed that the door hardware for the exit near room 1 required more force than allowed to open. NFPA 101: 7.2.1.7 (3) states, "It shall be constructed so that a horizontal force not to exceed 15 lbf (66 N) actuates the cross bar or push pad and latches." Also multiple other exit doors had panic hardware that was damaged and missing parts.

Interview with office manager revealed the facility was not aware that the exit door hardware needed to be repaired.

Based on visual observation the facility failed to provide exit signage for all required exits. Exit signs provide a route for occupants to reach safety. The deficient practice had the potential to affect 3 of 3 residents.
5 of 5 exits have signage that is deficient.

Findings:

During the facility tour, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was observed that the lobby exit sign is not illuminated. That the exit/emergency light by room 113 was not functioning. That the exit light by the chapel was hanging by its wiring. Also the exit signs on the main patient hall were either removed or not functioning.

Interview with office manager revealed the facility was not aware that exit signage was required.

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 3 of 3 residents.
1 of 3 smoke compartments have hazardous areas that are not separated.

Findings:

During the facility tour, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was observed that numerous rooms on the left side of the facility starting from the business office moving to the kitchen have been made into storage rooms. These rooms do not have self closures.


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

Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 3 of 3 residents.

Findings:

During the record review, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. the last semi-annual was conducted on 7/20/2020.

Interview with the office manager revealed the facility was not aware the semi-annual inspection was not conducted on the hood suppression system.

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 and that records of system acceptance, maintenance and testing are readily available. 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 3 of 3 residents.

Findings:

During the facility tour and the record review, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. the facility was unable to provide the fire alarm inspection reports and documentation of the smoke sensitivity test.

Interview with the office manager revealed the facility was not aware that the required inspections documentation was not available.

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 25. NFPA 25:5.2.1.1.2 states "Any Sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded;", which results in protection of life and property. This deficiency has the potential to affect 3 of 3 residents.

Findings:

During the facility tour, on 4/5/2021 through 4/6/2021 it was observed that:

1) That in the exterior rooms for the facility that the sprinkler heads were rusted.
2) that conduit had been tied to the sprinkler piping in the ADL office.
3) That the last inspection had been provided on 10/11/2019.

Interview with the office manager revealed the facility was aware that the annual inspection had not been conducted on the automatic sprinkler system.

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 3 of 3 residents.

Findings:

During the facility tour, on 4/5/2021 through 4/6/2021 it was observed that numerous rooms have openings throughout the facility around sprinkler piping, electrical wiring, conduits, and utilities leading into the corridors. This was observed above and below the dropped ceiling.

Interview with the office manager revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. NFPA 90A also requires fire dampers and ceiling dampers to be maintained in accordance with NFPA 80. NFPA 80:19.4.1.1 states "The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 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 3 of 3 residents.
2 of 3 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour, on 4/5/2021 through 4/6/2021 it was observed that multiple HVAC systems were present. Two systems had transfer grilles and/or louvers present in the corridor wall by clean utility and storage. In the back mechanical room the HVAC duct penetrating the wall appeared to have a damper present. By room 9 a large louver was present in the corridor wall that went into the mechanical room with old HVAC units and storage. The facility had no documentation present for when their fire dampers were last inspected and locations where installed.

Interview with the office manager revealed the facility was not aware the HVAC system was using the corridors as a return air plenum and that fire dampers required inspections.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 3 of 3 residents. 4 of 4 quarters in 2020-2021 were deficient.

Findings:

During the record review, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was noted that no fire drills have been performed and/or documented for the last 4 quarters on all shifts.

Interview with the office manager revealed the facility was aware fire drills were not being held for all shifts.

Based on visual observation, the facility failed to assure that the policy on smoking required all smoking areas to be supplied with a metal, self-closing container. Cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion. This deficient practice could potentially affect 1 of 3 residents.

Findings:

During the facility tour, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was observed that the ashtrays were not noncombustible material and metal containers with self-closing cover devices into which ashtrays can be emptied were not provided.


Interview with office manager revealed the facility was not aware the containers in the smoke area did not meet the requirements.

Based on visual observation the facility failed to assure that installed fire doors were inspected and maintained. The fire doors restrict the movement of fire from one compartment to another. NFPA 80:5.2.3.5.2 states, "As a minimum, the following items shall be verified: (1) Labels are clearly visible and legible. (2) No open holes or breaks exist in surfaces of either the door or frame. (3) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (4) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (5) No parts are missing or broken. (6) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (7) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (8) If a coordinator is installed, the inactive leaf closes before the active leaf. (9) Latching hardware operates and secures the door when it is in the closed position. (10) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (11) No field modifications to the door assembly have been performed that void the label. (12) Meeting edge protection, gasketing and edge seals, where required, are inspected to verify their presence and integrity. (13) Signage affixed to a door meets the requirements listed in 4.1.4." The deficient practice had the potential to affect 3 of 3 residents.

Findings:

During the facility tour and record review, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was observed that the rated doors by the nurse station did not fully close when the magnetic holds were released. Also the fire doors by room 13 and 11 had door holds that were not approved and prevented the doors from closing in the event of a fire. No annual inspection and/or documentation was provided for any of the fire rated doors for the facility.

Interview with the office manager revealed the facility was not aware that the fire doors had not been properly inspected and maintained.

Based on visual observation the facility failed to assure that proper maintenance was being provided for the electrical systems, receptacles and electrical housing units and that they were provided with listed covers. NFPA 70:110-12(A) states, " Unused cable or raceway openings in boxes, raceways, auxiliary gutters, cabinets, cutout boxes, meter socked enclosures, equipment cases, or housing shall be effectively closed to afford protection substantially equivalent to the wall of the equipment. "
This deficient practice could potentially affect 3 of 3 residents.


Findings:

During the facility tour, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was observed that numerous areas throughout the facility had exposed and damaged wiring. On the first hall with the side exit and exit sign was hanging by it's electrical wiring. The bathroom before the exit sign had wiring outside the ceiling light enclosure. The electrical cords in the patient dining area were damaged with the prongs bent and wiring showing through the exterior covering. The exit signs were removed from the main patient hall with the junction boxes open with exposed wires. In patient rooms 1 and 5 outlets beside the patient bed had been damaged with parts of the receptacle exposed. It was also noted that patient bed in room #5 had the plug replaced or altered. It also appeared throughout the facility that electrical receptacles near water were not provided with GFCI as required by NFPA 70:210.8 (B) Other Than Dwelling Units. All 125-volt, singlephase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel. (1) Bathrooms (2) Kitchens (3) Rooftops (4) Outdoors (5) Sinks — where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink. (6) Indoor wet locations (7) Locker rooms with associated showering facilities (8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used.

Interview with the office manager revealed the facility was not aware of the open electrical housings and missing GFCI protection.

Based on record review, the facility failed to provide receptacles not listed as hospital-grade at at patient bed locations are tested at intervals not exceeding 12 months. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. The deficient practice had the potential to affect 3 of 3 residents.

Findings:

During the record review, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was found that no documentation was present for any testing and maintenance for the electrical systems in the facility. This facility has receptacles not listed as hospital-grade at patient bed locations.

Interview with the office manager revealed the facility was not aware that the testing, maintenance, and documentation for the electrical systems was not being performed.

Based on visual observation the facility is lacking a generator remote annunciator that is storage battery powered 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. The deficiency has the potential to affect 3 of 3 patients.

Findings:

During the facility tour on April 5, 2021 between the hours of 3:00 p.m. to 5:30 p.m. it was observed this facility was lacking an installed hard wired remote generator annunciator in a constantly attended location such as the nurse's station. (NFPA 110:5.6.5.2 (4) A individual alarm indicator to annunciate any of the conditions listed in Table 5.6.5.2.) (Was first cited on the initial survey for CMS on April 11,2018)

Interview with the Office Manager revealed the facility was aware a hard wired remotely located generator annunciator located in a constantly attended location is required. The Administrator is in discussions with the owner of the Hospital facility to install a wired generator annunciator in a constantly attended location such as the nurse's station.

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 3 of 3 residents.

Findings:

During the facility tour and record review on April 5, 2021 between the hours of 3:00 p.m. to 5:30 p.m. the following was observed:

1) The generator was lacking a remote manual stop and lacking a properly labeled sign located outside the generator weatherproof enclosure prime mover housing. (NFPA 110:5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. NFPA 110:5.6.5.6.1 The remote manual stop station shall be labeled.) (This was first cited on the initial survey for CMS on April 11,2018)

2) Weekly generator inspections were not performed ad/or documented for numerous weeks.

3) The generator was not exercised under load.

Interview with the Office Manager revealed the facility has been in discussions with the owner of the Hospital facility to install the required remote manual stop with the properly labeled signage located outside of the generator weatherproof enclosure. The facility was not aware that the weekly and monthly inspections were not being conducted.

Based on visual observation, the facility failed to assure that all power strips are being used with general caution and that extension cords are not being used as a substitute for fixed wiring of a structure as per NFPA 99 and NFPA 70. Power strips in the patient care vicinity may not be used for non-PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms meet UL 1363.Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. The deficient practice had the potential to affect 3 of 3 residents.

Findings:

During the facility tour, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was observed that extension cords were being used as a substitute for fixed wiring in the patient dining area. It was also found that power strips (surge protectors) were being used as an extension cord in the Therapy and social room office. Surge protector were used in patient room 5 for the patient bed, room 1 for non-PCREE. A surge protector was also used in the med room suspended by its cord. A surge protector was also found to be used for the vending machine before the nurse station.


Interview with the office manager revealed the facility was not aware that extension cords are being used as a substitute for fixed wiring and that surge protectors were being used improperly.

Based on visual observation, the facility failed to assure that a precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion.


Findings:

During the facility tour, on 4/5/2021 between the hours of 3:00 p.m. to 5:30 p.m. it was observed that the cylinder storage room did not have signage stating CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.


Interview with the office manager revealed the facility was not aware that the signage was not provided for the oxygen storage room.