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Based on record review and staff interview, the facility failed to document that the Life Safety and Critical Branches of the emergency electrical system switched to emergency power within 10 seconds. This practice had the potential for occupants to be left in darkness during an extended period in the event of a power outage.

Findings are:
Record review on 5/25/22, at 3:07 pm of generator inspection reports and testing revealed transfer elapsed time from normal to emergency power was not documented during monthly load tests.

In an interview on 5/25/22, at 3:07 pm, Administration C confirmed the documentation was incomplete.

NFPA 99, 2012, 6.4.3 Performance Criteria and Testing (Type 1 EES).
6.4.3.1 Source. The life safety and critical branches shall be installed
and connected to the alternate power source specified in
6.4.1.1.4 and 6.4.1.1.5 so that all functions specified herein for
the life safety and critical branches are automatically restored to
operation within 10 seconds after interruption of the normal
source.

A. Based on observation and staff interview, the facility failed to ensure a magnetically locked exit door would open with pressure applied to the release device. This condition would slow the evacuation of occupants.

Findings are:
Observation on 5/25/22, at 11:30 am revealed the delayed egress unlocking sequence did not initiate when force was applied to the panic bar on the door for the west door leaf from the Indoor Playground Exit that was adjacent to Door E119.

In an interview on 5/25/22, at 11:30 am, Administration B confirmed the door did not open with pressure applied to the panic bar.

NFPA 101, 2012, 7.2.1.6.1 Delayed-Egress Locking Systems.
7.2.1.6.1.1 Approved, listed, delayed-egress locking systems
shall be permitted to be installed on door assemblies serving
low and ordinary hazard contents in buildings protected
throughout by an approved, supervised automatic fire detection
system in accordance with Section 9.6 or an approved,
supervised automatic sprinkler system in accordance with Section
9.7, and where permitted in Chapters 11 through 43, provided
that all of the following criteria are met:
(3)*An irreversible process shall release the lock in the direction
of egress within 15 seconds, or 30 seconds where approved
by the authority having jurisdiction, upon application
of a force to the release device required in 7.2.1.5.10
under all of the following conditions:
(a) The force shall not be required to exceed 15 lbf (67 N).



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B. Based on observation and interview the facility allowed the use of a thumb lock on a sliding door. This deficient practice would allow the door to lock and prevent occupants from exiting.

Findings are:
Observation on 5/25/22 at 11:52 am revealed, a thumb lock was in working order on the sliding glass door in the north entry way.

During an interview on 5/25/22 at 11:52, Administration C confirmed the thumb lock.

A. Based on observation, record review and interview, the facility failed to assure a horizontal exit was properly constructed. This deficient practice would allow fire to spread throughout the facility in the event of a fire.

Findings are:
Documentation review on 5-26-22 at 11:33 am, of a building code review dated 1-30-2015 revealed a deficiency citing:
1. Where the two-hour fire rated walls serving horizontal exits on the Lower Level terminate at outside walls, and the outside walls are at an angle of less than 180 degrees for a distance of 10 feet on each side of the horizontal exit, the outside walls shall have not less than a one-hour fire resistance rating with not less than 3/4-hour fire protection rating opening protectives for a distance of 10 feet on each side of the horizontal exit. LSC, 7.2.4.3.2

Observations on 5-26-22 at 11:40 am revealed the windows on the lower level were not located 10 feet from the 2-hour fire rated wall.

During an interview on 5-26-22 at 11:42 am, Administration Staff A and B confirmed the findings and failed to verify correction of the deficiency on the building plan review.


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B. Based on observation and staff interview, the facility failed to maintain the construction of a horizontal exit/2-hour fire barrier. This condition would allow fire to spread throughout the facility in the event of a fire.

Findings are:
Observation on 5/25/22, from 11:20 am to 2:10 pm revealed:
1. The 90-minute E108A fire doors did not positively latch when self-closed.
2. Above ceiling at the E108A fire doors, a four inch conduit was missing a firestop plug, and fire caulking had pulled out of a fire alarm wire pass-through conduit that penetrated the 2-hour fire wall.

In an interview on 5/25/22, from 11:20 am to 2:10 pm, Administration B confirmed the unsealed penetrations.

NFPA 101, 2012, 7.2.4.3 Fire Barriers.
7.2.4.3.1 Fire barriers separating buildings or areas between
which there are horizontal exits shall have a minimum 2-hour
fire resistance rating, unless otherwise provided in 7.2.4.4.1,
and shall provide a separation that is continuous to the finished
ground level. (See also Section 8.3.)

Based on observation and interview the facility failed to ensure dead ends of over 30 feet were not located in the building. This deficient practice would confuse occupants, if smoke, fire and gasses were present when exiting into the dead end which would delay evacuation in an emergency.

Findings are:
Observation on 5-26-22 at 11:18 am revealed, an approximate distance of 40 feet to an unmarked exit door in the pool/therapy corridor C154, which created a dead-end.

During an interview on 5-26-22 at 11:18 am, Administration Staff A confirmed the 40-foot dead-end.

19.2.5.2 Every exit or exit access should be arranged, if practical and feasible, so that no corridor has a dead end exceeding 30 ft (9.1 m).

Based on observation and interview, the facility failed to assure an exit sign for the second required exit was visible. This deficient practice has the potential to delay or cause confusion during an emergency as occupants would not be aware of the exit.

Findings are:
Observations on 5-25-22 at 11:55 am and 12:05 pm revealed:
1. Looking west in corridor D143 no exit sign was visible.
2. Looking west in corridor D104 no exit sign was visible.

During an interview on 5-25-22 at 11:55 am and 12:05 pm, Administration Staff A confirmed the exit signs failed to be visible.

A. Based on observation and interview, the facility failed to provide smoke resistant enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridors.

Findings are:
Observation on 5-25-22 between 11:02 am and 2:32 pm revealed:
1. Door C141 to a storage room over 100 square feet failed to provide self-closing device.
2. Door C142 to a lab, equipped with a self-closing device failed to latch within the doorframe.
3. The west door C149 to a storage room failed to provide a self-closing device.
4. The closure was removed on door C157.
5. Door C173 to laundry room, equipped with a self-closing device failed to latch within the doorframe.
6. An approximate 6-inch circular unsealed penetration in the wall of room C028.

During an interview on 5-25-22 between 11:02 am and 2:32, Administration Staff A confirmed the door failed to latch.


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B. Based on observation and staff interview, the facility failed to separate hazardous areas with smoke resistive partitions. This condition would allow smoke to migrate into the exit corridors.

Findings are:
Observation on 5/25/22, from 11:33 am to 11:59 am revealed:
1. The self-closure had been removed from the Indoor Play Area E149 Storage Room Door.
2. A conduit and a fire sprinkler pipe were not sealed in the rated barriers of the F062 Communication Room.

In an interview on 5/25/22, from 11:33 am to 11:59 am, Administration B acknowledged the findings.



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C. Based on observation and interview, the facility failed to provide smoke resistant enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridors.

Findings are:
Observation on 5/25/22 at 11:22 am revealed, door A154 to a storage room failed to latch into the frame.

During an interview on 5/25/22 at 11:22 am, Administration C confirmed the door failed to latch.

Based on observation and staff interview, the facility failed to install an alcohol-based hand rub (ABHR) dispenser, so it wasn't directly over an ignition source. This condition had the potential for the flammable liquid to ignite when dispensed.

Findings are:
Observation on 5/25/22, at 11:10 am revealed the ABHR in the F161 Soiled Work Room was installed directly over a light switch.

In an interview on 5/25/22, at 11:10 am, Administration B confirmed the location of the dispenser over the light switch.

A. Based on observation and interview, the facility failed to provide audio/visual devices in exam rooms and sleeping rooms. This deficient practice would not notify occupants in the areas of an emergency.

Findings are:
Observation on 5-25-22 between 11:05 am and 2:38 am revealed:
1. Exam room C138 failed to provide an audio/visual device.
2. Exam room C139 failed to provide an audio/visual device.
3. Treatment room C150 failed to provide an audio/visual device.
4. Staff sleeping room C138 failed to provide an audio/visual device.

During an interview on 5-25-22 between 11:05 am and 2:38 am, Administration Staff A confirmed the lack of an audio/visual devices.



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B. Based on observation and interview, the facility failed to provide audio / visual devices in required areas of the building. This deficient practice would not notify occupants in the areas of an emergency.

Findings are:
Observation on 5/25/22 at 11:14 am revealed, the chapel failed to provide an audio / visual device.

During an interview on 5/25/22 at 11:14 am, Administration C confirmed the lack of an audio / visual.

Based on interview and record review, the facility failed to provide a complete policy was in place regarding the procedures to be taken in the event that the fire alarm was out of service for more than four hours in any twenty-four hour period. The lack of written policies and procedures could result in staff failing to implement interim measures in the event of an emergency which affects all occupants.

Findings are:
Record review on 5-26-22 at 12:35 pm of the fire alarm fire watch revealed:
1. The policy failed to include the authorities having jurisdiction would be contacted.
2. The policy failed to include individuals doing fire watch has ready access to fire extinguishers.
3. The policy failed to include individuals doing fire has ability to promptly notify the fire department.
4. Policies for fire watch failed to be provided in only one specific manual.

During an interview on 5-26-22 at 12:35 am, Maintenance Staff D confirmed the lack of a complete fire alarm fire watch policy.

NFPA Standard:
When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on interview and record review, the facility failed to provide a complete policy regarding the procedures to be taken in the event that the fire sprinkler system was out of service for more than ten hours in any twenty-four hour period. The lack of written policies and procedures could result in staff failing to implement interim measures in the event of an emergency.

Findings are:
Record review on 5-26-22 at 10:52 am, of the sprinkler fire watch procedures revealed:
1. Several different policies with conflicting information.
2. Policy failed to have complete information regarding a preplanned and emergency plan and failed to assure all supporting individuals be contacted.
3. Policies for fire watch failed to be provided in only one specific manual.


During an interview on 5-26-22 at 10:52 am, Administration Staff D confirmed the lack of specific items in the fire watch policy.

NFPA Standard:
2011, NFPA 25
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

A. Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke. This deficient practice would allow smoke, fire, and gases to migrate into the egress corridors.

Findings are:
Observation on 5-25-22 between 11:03 and 2:23 pm revealed:
1. Double doors C145 to the Rehab day lounge had an excessive gap.
2. Double doors C177 to the therapy room had an excessive gap.
3. Door D155 to back of house failed to latch.
4. Door D070 to back of house latching hardware was removed.
5. Door D056A to back of house latching hardware was removed.

During an interview on 5-25-22 between 11:03 and 2:23 pm, Administration Staff A confirmed the findings


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B. Based on observation and interview, the facility failed to maintain doors to ensure smoke separation of the egress corridor. This deficient practice would allow smoke, fire, and gases to migrate from those rooms into the egress corridors.

Findings are:
Observation on 5/25/22 at 11:03 and 11:10 am revealed,
1. Door A165 to the main level kitchen had an excessive gap.
2. Double doors A140 to the conference room had an excessive gap.
3. Double doors A140A to the conference room had an excessive gap.

During an interview on 5/25/22 at 11:03 and 11:10 am, Administration C and Maintenance A confirmed the gaps.

A. Based on observation and interview, the facility allowed the smoke compartments doors to have excessive gaps and not latch which would allow smoke, fire, and gases to migrate to other smoke compartments.

Findings are:
Observation on 5-25-22 at 11:03 am, and 2:06 pm revealed,
1. Double doors C116 smoke door excessive gap.
2. East smoke door C183 equipped with latching device failed to latch within the doorframe.
3. Double doors D002 smoke doors excessive gap.

During an interview on, 5-25-22 between 11:03 am, Administration Staff A confirmed the failure to latch and excessive gaps.


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B. Based on observation and interview, the facility allowed the smoke compartments doors to have excessive gaps and not latch which would allow smoke, fire, and gases to migrate to other smoke compartments.

Findings are:
Observation on 5/25/22 at 11:03 am, and on 5/26/22 at 10:42 am revealed,
1. Door A147 from the dining room to the link did not latch into the frame
2. Door A147 from the dining room to the link had an excessive gap.
3. Double doors F100 had an excessive gap at the top of the doors.

During an interview on, 5/25/22 at 11:03 am, and on 5/26/22 at 10:42 am, Administration C and Maintenance A confirmed the failure to latch and excessive gaps.

Based on interview and record review, the facility failed to provide a complete fire safety (evacuation) plan. This deficient practice would delay evacuation and affected all occupants in all smoke compartments.

Findings are:
Record review on 5-26-22 at 1:17 pm revealed:
1. Evacuation policy failed to detail the evacuation order by proximity to a fire. Specifically, that residents would be
rescued from the room of fire origin, on both sides of the room of fire origin, and across the hall.
2. Evacuation policy failed to detail that the room of fire origin shall not be crossed, before continuing to evacuate the
remainder of the smoke compartment.
3. Policies for evacuation failed to be provided in only one specific manual.

During an interview on 5-26-22 at 1:17 pm, Administration Staff D confirmed the information was not present in the fire procedure and that the facility failed to assure that policies were provided in only specific manual.

NFPA Standard:
NFPA 101, 2012, 19.7.2.2
Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

18.7.2.3.1
All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

18.7.2.3.2
All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

18.7.2.3.3
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Based on observation and interview, the facility allowed the use of a space heater without documentation of the heating element temperature. This deficient practice could cause a fire.

Findings are:
Observation on 5/25/22 at 11:31 am revealed, room C105 had a space heater in use with no documentation stating the maximum temperature of the heating element.

During an interview on 5/25/22 at 11:31 am, Administration C stated there is no policy on space heaters.

Based on record review and staff interview, the facility failed to document that the Life Safety and Critical Branches of the emergency electrical system switched to emergency power within 10 seconds. This practice had the potential for occupants to be left in darkness during an extended period in the event of a power outage.

Findings are:
Record review on 5/25/22, at 3:07 pm of generator inspection reports and testing revealed transfer elapsed time from normal to emergency power was not documented during monthly load tests.

In an interview on 5/25/22, at 3:07 pm, Administration C confirmed the documentation was incomplete.

NFPA 99, 2012, 6.4.3 Performance Criteria and Testing (Type 1 EES).
6.4.3.1 Source. The life safety and critical branches shall be installed
and connected to the alternate power source specified in
6.4.1.1.4 and 6.4.1.1.5 so that all functions specified herein for
the life safety and critical branches are automatically restored to
operation within 10 seconds after interruption of the normal
source.

Based on observation and interview, the facility failed to ensure combustible materials were stored at least 5 feet from oxygen and failed to provide signage above oxygen cylinders. This deficient practice would increase the potential for an ignition of a fire.

Findings are:
Observation on 5-25-22 at 2:12 pm revealed:
1. Combustible items were stored less than 5 feet from oxygen cylinders in Room D060 soiled linen.
2. No signage above the stored oxygen cylinders in room D060 to indicated full or empty.

During an interview on 5-25-22 at 2:12 pm, Administration Staff A confirmed the findings.

NFPA Standard:
NFPA 99, 2012, 11.3.2.3
Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour

A. Based on observation, record review and staff interview, the facility failed to properly train staff in transfilling procedures. This condition could cause injury to staff performing the transfilling.

Findings are:
Observation on 5-25-22, at 12:01 pm and 2:20 pm revealed:
1. PPE was not provided in the Oxygen Transfilling Room D071.
2. PPE was not provided in the Oxygen Transfilling Room D165.

During an interview on 5-25-22, at 12:01 pm and 2:20 pm Administration Staff A confirmed the lack of PPE available in the transfilling room, and that the facility procedures required the PPE.

Record review on 5-25-22, at 3:30 pm, revealed PPE was required for staff performing transfilling in the facility transfilling procedures.


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B. Based on observation, record review and staff interview, the facility failed to properly train staff in transfilling procedures. This condition could cause injury to staff performing the transfilling.

Findings are:
Observation on 5/25/22, at 3:20 pm revealed PPE was not provided in the Oxygen Transfilling Room E189A.

In an interview on 5/25/22, from 3:20 pm to 3:30 pm Administration C confirmed the lack of PPE available in the transfilling room, and that the facility procedures required the PPE.

Record review on 5/25/22, at 3:30 pm revealed PPE was required for staff performing transfilling in the facility transfilling procedures.

NFPA 99, 2012, 11.5.2.3 Transfilling Liquid Oxygen. Transfilling of liquid oxygen
shall comply with 11.5.2.3.1 or 11.5.2.3.2, as applicable.
11.5.2.3.1 Transfilling to liquid oxygen base reservoir containers
or to liquid oxygen portable containers over 344.74 kPa
(50 psi) shall include the following:
(1) A designated area separated from any portion of a facility
wherein patients are housed, examined, or treated by a
fire barrier of 1 hour fire-resistive construction.
(2) The area is mechanically ventilated, is sprinklered, and
has ceramic or concrete flooring.
(3) The area is posted with signs indicating that transfilling is
occurring and that smoking in the immediate area is not
permitted.
(4) The individual transfilling the container(s) has been
properly trained in the transfilling procedures.
11.5.2.3.2 Transfilling to liquid oxygen portable containers at
344.74 kPa (50 psi) and under shall include the following:
(1) The area is well ventilated and has noncombustible flooring.
(2) The area is posted with signs indicating that smoking in
the area is not permitted.
(3) The individual transfilling the liquid oxygen portable container
has been properly trained in the transfilling procedure.
(4) The guidelines of CGA P-2.6, Transfilling of Low-Pressure
Liquid Oxygen to be Used for Respiration, are met.