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Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice had the potential to affect 10 of 10 residents.

Findings:

During the facility tour and interview with staff, between the hours of 9:00AM to 4:00PM it was observed that multiple doors required keys to gain access into the space. The bathroom door in the office area required a key to gain access and staff was not aware of who would have a key to open. The conference room that is now used for storage was also locked. The staff member had to get maintenance to come and pop the lock for the room to be inspected.


Interview with the supervisor revealed the facility was not aware that keys were required to gain access to these spaces and that the keys were not readily available.

Based on visual observation the facility failed to assure that all doors within an exit passageway were held open by an approved means. When doors to stairwells, smoke barriers, horizontal exits or hazardous areas are propped open it provides an opportunity to allow fire and/or smoke to flow freely throughout the facility. This deficient practice has the potential to affect 10 of 10 residents.

Findings:

During the facility tour, between the hours of 9:00AM to 4:00PM it was observed that several doors throughout the facility with self-closing and/or automatic closures were being propped open. The front office had the door held open with a wooden block as well as the door to the oxygen storage room within the office. Other office area doors were also propped open. The door that led to the shower and storage area was dragging the floor not allowing the closure to function as designed and therefore the door being stuck open.

Interview with the Supervisor revealed the facility was not aware that the doors were being propped open or needed repairing to close properly.

Based on visual observation the facility failed to provide a fire alarm system that is activated by manual means, detection devices and waterflow alarms. When the building is equipped with life safety systems, that offer complete coverage, the occupants maintain a sense of security in an emergency. This deficiency has the potential to affect 10 of 10 residents.

Findings:

During the facility tour and record review, between the hours of 9:00AM to 4:00PM it was observed that the manual pull station for the fire alarm is being blocked by a table and chairs, and exercise equipment in the physical therapy area.

Interview with the Supervisor revealed the facility was not aware that the manual pull station to activate the fire alarm system was being blocked.

Based on visual observation the facility failed to provide doors in the 1 hour smoke barrier wall that are self-closing upon activation of one or all of the following fire protection features, the required fire alarm system, local smoke detectors, automatic sprinkler system, or loss of power.
This deficiency could affect 5 of 5 patients if not corrected.

Findings:

During the facility tour, between the hours of 9:30 a.m. and 10:30 a.m. the smoke barrier doors to the patient corridor were observed dragging on the floor and not closing to provide a smoke tight seal upon activation of the fire alarm system. Smoke barrier doors are designed to keep smoke from passing from one compartment to another.

Interview with maintenance supervisor revealed the facility was not aware the smoke barrier doors were dragging on the floor and unable to create a smoke tight seal.
Surveyor: Lorio, Gail

Based on visual observation the facility failed to provide the designated smoking area, located at front of building with ashtrays of non-combustible material and safe design. Also, no metal containers with self-closing cover devices which ashtrays can be emptied were not available in the smoking area..
This deficient practice could affect 5 of 5 patients if not corrected.

Findings:

During the facility tour between the hours of 9:30 a.m. and 10:30 a.m. it was observed the ashtrays provided in the designated smoking area were not made of non-combustible material, and metal containers with self-closing cover devices designed for ashtrays to be empted into were not readily available in the smoking area located at the front of the building.

Interview with the maintenance supervisor revealed the facility was not aware that ashtrays made of non-combustible material and self-closing metal containers were needed in the smoking area

Based on visual observation the facility failed to provide a remote annunciator panel in working condition identifying all alarm conditions of the generator .
This deficient practice could affect 5 of 5 patients.

Findings:

During the facility tour and testing of the generator, between the hours of 10:00 a.m. and 10:30 a.m., the remote annunciuator panel which is hard-wired to identity alarm conditions of the generator located at the nurse's station was not indicating if the emergency power source was supplying a full load of power to the building.

Interview with the maintenance supervisor revealed the facility was not aware the annunciator panel was not showing if the emergency power source was supplying a full load of power to the building. .

Based on visual observation and record review the facility failed to provide documentation for the weekly testing of the generator. NFPA 110 requires a written report of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
This deficient practice could have the potential to cause harm to 5 of 5 patients.

Findings:

During the facility tour between the hours of 10:30 a.m. and 11:00 a.m. review of records revealed the facility had no documentation of a weekly exercising cycle of the generator.

Interview with the maintenance supervisor revealed the facility was documenting the monthly load test of the generator but was not aware that the weekly exercising of the generator performed on Sunday nights at 10:00 p.m. was required to be included in the record keeping.