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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.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was observed at multiple ramps and stairs from marked exits that the ground and concrete had collapsed. The collapse in these areas have caused drop offs, unlevel walking surfaces, and damaged the handrails and guardrails.

Interview with the Administrator at 3:30pm revealed the facility was aware that multiple ramps and stairs out of marked exits in the corridor were obstructed and were not to full instant use.

Based on observation, the facility failed to provide free egress from all required exits. Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:

Findings:

During the facility tour on 3/19/2019, at 10:00am to 3:30pm, it was observed that the exit door from the cafeteria had slide bolts added to both of the double doors. In the receiving area the fenced in portion had the entrance gate pad locked.

Interview with the Administrator at 3:30pm revealed the facility was not aware that the slide bolts are the pad lock was being utilized.

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.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 the following observations were made:

1) Throughout the entire facility doors with closures were being held open by wooden and metal wedges.
2) Numerous areas being used for storage and other hazardous areas have doors that are not provided with automatic or self-closing devices.
3) Multiple corridor doors equipped with magnetic hold devices can no longer connect with the contact to hold the door opened as designed.

Interview with the Administrator revealed the facility was not aware that the doors were being propped open, needed closures, and that the magnetic holds were not making contact with the doors.

Based on visual observation the facility failed to maintain the ramps as per NFPA 101. NFPA 101:7.2.5.1 states "Every ramp used as a component in a means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.5".

Findings:

During the facility tour, between the hours of 10:00am and 3:30pm it was observed that several of the ramps have had the slope, level landings, handrails, and guardrails affected by portions collapsing and/or sinking.

Interview with the Administrator at 3:30pm revealed the facility was aware of the areas affected by the ground collapsing and/or sinking obstructing the egress.

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. Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was observed that numerous areas including ramps and stairs had unleveled walking surfaces due to collapsed areas. It was also observed out one of the back exits was a single covered parking spot that was elevated with no ramp or stair provided.

Interview with the Administrator at 3:30pm revealed the facility was aware of the unleveled walking surfaces.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was observed that almost all emergency lights were non-functional. Multiple emergency lights were also observed to have had the mounting device broken and were hanging by the lights wiring.

Interview with the Administrator at 3:30pm revealed the facility was not aware that the emergency lighting throughout the facility was non-functional.

Based on visual observation the facility failed to provide exit signage for all required exits with continuous illumination. Exit signs provide a route for occupants to reach safety.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was observed that the exit signage was not provided with continuous illumination and emergency lighting.


Interview with the Administrator revealed the facility was not aware that the exit signs were not illuminated.

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.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was observed that multiple hazardous areas throughout the facility did not have doors provided with self-closing or automatic closing hardware. This included previous patient rooms now being used for storage and the physical therapy room being used for oxygen storage.


Interview with the Administartor at 3:30pm 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.

Findings:

During the record review, between the hours of 10:00am to 3:30pm on 3/21/2019 it was found that the kitchen suppression system was last inspected and serviced in 2017. It was also observed that the cooking equipment had been moved from the original designed locations for the suppression system to operate correctly. It was also noted that food was on the front left burner of the range cooking with no one present in the kitchen area.

Interview with one of the staff members and the Administrator revealed the facility had a cooking (grease) fire a few weeks prior. The fire was located on the front left burner of the range. The kitchen suppression system was not activated and the staff did not manually activate the system. Staff responded to the fire and three ABC fire extinguishers were utilized to suppress the fire. A K-class extinguisher was present next to the hood, however the staff did not know to use it for grease fires.

Interview with the Administrator at 3:30pm revealed the facility was not aware the semi-annual inspection was not conducted on the hood suppression system and that the appliances in the kitchen were not covered properly by 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. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency.

Findings:

During the facility tour and the record review, between the hours of 10:00am to 3:30pm on 3/19/2019 it was found that the fire alarm system had been yellow tagged on 9/15/2018 for the tamper on the sprinkler riser needing to be replaced. It was also observed that throughout the entire facility ceiling tiles were missing that could prevent the smoke detectors from operating properly.

Interview with the Administrator revealed the facility was not aware that the fire alarm system was yellow tagged and that the missing ceiling tiles could effect the fire alarm system.

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.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was observed that:

1) Throughout the facility was numerous sprinkler heads corroded.
2) Throughout the facility the sprinkler heads were dirty.
3) Throughout the facility escutcheon plates were missing.
4) Throughout the facility ceiling tiles were missing that could result in the sprinkler system not operating as designed.

Interview with the Administrator at 3:30pm revealed the facility was not aware that the annual inspection had not been properly conducted on the automatic sprinkler system and that sprinkler heads were corroded, dirty, missing escutcheon plates, and that the missing ceiling tiles could cause the sprinkler system to not function as designed.

Based on visual observation the facility failed to assure that the fire extinguishers were inspected and tested in accordance with the Life Safety Code and NFPA 10. Fire extinguishers are available to extinguish small fire or smoke emergencies.

Findings:

During the facility tour and the record review, between the hours of 10:00am to 3:30pm on 3/19/2019 it was found that all extinguishers in the facility were last inspected in 9/2017. It was observed that multiple extinguishers appeared to be missing due to the empty fire extinguisher mounts. Also three fire extinguishers were present in the kitchen fully discharged due to use on a kitchen fire weeks prior.

Interview with the administrator revealed the facility was not aware that the annual and monthly inspection on the fire extinguishers had not been conducted.

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.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was observed that throughout the facility were missing ceiling tiles and penetrations in the walls on both the side of the corridor and patient room.

Interview with the Administrator at 3:30pm 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 and record review the facility failed to provide inspection as per NFPA 80 on the swinging doors with fire door hardware in the corridors. NFPA 80:5.2.4.2 states " As a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position".


Findings:

During the record review and facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was found no documentation was provided for door inspections. It was observed that multiple corridor doors did not fully open, could not come in contact with magnetic hold, and the panic hardware did not function properly.

Interview with the Administrator at 3:30pm revealed the facility was not aware that the doors were not being inspected and maintained properly.

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.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was found that the facility did not have a life safety plan showing the smoke compartments and the ratings of the walls. The areas believed to have been rated were observed and had penetrations and gaps present.

Interview with the Administrator revealed the facility was not aware of unsealed penetration and that the life safety plans were not onsite.

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.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was found that the facility did not have a life safety plan showing the smoke compartments and the ratings of the walls. It was observed that ceiling tiles were missing, penetrations, and gaps were present in smoke barriers throughout the facility.

Interview with the Administrator revealed the facility was not aware of unsealed penetrations and gaps in the smoke barriers.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. NFPA 70:110.12(A) states "Unused Openings. Unused openings, other than those intended for the operation of equipment, those intended for mounting purposes, or those permitted as part of the design for listed equipment, shall be closed to afford protection substantially equivalent to the wall of the equipment". Improper wiring creates a high risk of injury and/or death.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 observations noted that throughout the facility numerous electrical panels had missing blanks leaving breaker slots open. It was also observed that some of the panels did not fully enclose the panels.

Interview with the Administrator at 3:30pm revealed the facility was not aware of the open breaker slots in the electrical panels.

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. 1 of 4 quarters in 2018-2019 were deficient.

Findings:

During the record review, between the hours of 10:00am to 3:30pm on 3/19/2019 it was found that no records were available for the second quarter of 2018.

Interview with the Administrator revealed the facility was not aware fire drills were not documented for the second quarter of 2018.

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.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm it was observed that in the center exterior portion of the facility numerous cigarette butts were present all around the ramps. No metal, self-closing containers were provided.

Interview with the Administrator revealed the facility was not aware that smoking was occurring in these areas.

Based on visual observation the facility failed to provide mobile containers for dirty linen and trash collection that do not exceed the recommended capacity of 32 gallons. When hazardous materials are not stored in an area that is separated from other parts of the building, the risk of a fire/smoke emergency increases. This deficient practice could potentially affect of residents.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was observed that the room labeled biohazard near the loading dock had several large bins of uncollected trash exceeding the 32 gallon capacity present in that room.

Interview with the Administrator revealed the facility was not aware that multiple bins were in that room.

Based on record review, the facility failed to provide 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.

Findings:

During the record review, between the hours of 10:00am to 3:30pm on 3/19/2019 it was found that no documentation was present for any testing and maintenance for the electrical systems in the facility.

Interview with the Administrator at 3:30pm revealed the facility was not aware that the testing, maintenance, and documentation for the electrical systems was not being performed.

Based on visual observation and record review, the facility failed to assure that the weekly inspection and twelve 30 minute load tests 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.

Findings:

During the record review, between the hours of 10:00am to 3:30pm it was found that no weekly or 30 minute load tests had been performed and documented for the generator.

Interview with the Administrator revealed the facility was not aware that the testing, inspection, and documentation was not provided for the emergency generator.

Based on record review the facility failed to provide the physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols.

Findings:

During the facility tour, between the hours of 10:00am to 3:30pm on 3/19/2019 it was found that the defibrillator at the nurses station was tagged for the inspection expiring on 10/26/2018. This was the only defibrillator present.


Interview with the Administrator at 3:30pm revealed the facility was not aware that the defibrillator did not have a current inspection.

Based on visual observation, the facility failed to handle oxygen cylinders and manifolds based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99).


Findings:

During the facility tour, between the hours of 10:00am to 3:30am on 3/19/2019 it was observed that in the oxygen storage room near the nurse station that oxygen cylinders were not being secured. One cylinder had been placed in a small trash like container and had already fallen over.


Interview with the Administrator revealed the facility was not aware that the oxygen cylinders were not being properly secured.