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Based on observation and interview, the facility failed to maintain the means of egress. This was evidenced by five 70-gallon shredded paper bins that were stored in the corridor and reduced the width of travel to less than 44 inches. This could result in a delay evacuating the building. This affected the limited-care area and 0 of 4 patients.


Findings:

During a tour of the facility and interview with the Director of Facilities (DOF) on 9/25/23, the means of egress was observed.

At 11:52 a.m., five large trash bins were observed in the corridor west of the Conference Room Entrance. The distance between the wastebins and the corridor wall was approximately 32 inches in width. Upon interview, the DOF stated that the waste bins were placed in the corridor temporarily but could be moved.

Based on observation, document review, and interview, the facility failed to maintain the exit signage. This was evidenced by exit signs along the evacuation route that were not illuminated. This could result in confusion or delay to exit the building during a fire or power outage. This affected 4 of 4 patients.



Findings:

During a tour of the facility, review of documents, and interview with the Director of Facilities (DOF) on 9/25/23, the exit signage was observed.

1. At 11:50 a.m., two exit signs were observed in the corridor west of the Conference Room which lead to the rehabilitation area. These exit signs were made of paper and were non-illuminated. Upon interview, the DOF stated that he did not know that the exit signs needed to be illuminated.

2. At 1:22 p.m., an exit sign was observed above the smoke barrier doors in the Skilled Nursing Facility (SNF) ward by Room 28. The exit sign was made of paper and was not illuminated. Upon interview, the DOF stated that they were in the process of replacing all the old exit signs and had not gotten to this sign yet.

3. At 3:29 p.m. a work order was provided indicating all but three exit signs were replaced. Documentation provided indicated that the three exit signs were missing the 90 minute annual testing. Upon interview, the DOF stated that the emergency lights and exit signs were replaced after the recertification survey for the Skilled Nursing Facility (SNF), which took place on 5/30/23 and that they were still in the processes of replacing all the old exit signs.

Based on document review and interview, the facility failed to maintain the Cooking Facilities. This was evidenced by the failure to provide an annual inspection of the commercial cooking equipment. This affected the limited care area of the building and 0 patients.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.
9.2.3 Commercial Cooking Equipment.
Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.
NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2014 Edition.
11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.

Findings:

During a review of records and interview with the Director of Facilities (DOF) on 9/25/23, documentation was requested.

At 3:35 p.m., the annual inspection of the fuel lines for the gas stove and range in the kitchen was missing. Upon interview, the DOF stated that an annual inspection of the commercial equipment was not performed because they did not know that it was required.

Based on document review and interview, the facility failed to maintain the Fire Alarm System (FAS). This was evidenced by the failure to perform semi-annual visual inspections, and testing on the Fire Alarm Control Panel (FACP) batteries. This could result in a malfunction of the FAS. This affected 4 of 4 patients.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1 * General.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.
NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
Table 14.3.1 column 2 heading was revised by a tentative interim amendment (TIA).
Table 14.3.1 Visual Inspection Frequencies
3. Batteries
(d) Sealed lead-acid: Initial/Reacceptance; Semiannually
5. Fire alarm control unit trouble signals: Weekly; Semiannually
8. Remote annunciators: Initial/Reacceptance; Semiannually
9. Initiating devices
(c) Electromechanical releasing devices: Initial/Reacceptance; Semiannually
(e) Manual fire alarm boxes: Initial/Reacceptance; Semiannually
(f) Heat Detectors: Initial/Reacceptance; Semiannually
(h) Smoke detectors: Initial/Reacceptance; Semiannually
(i) Supervisory signal devices: Initial/Reacceptance; Semiannually
13. Alarm notification appliances- supervised: Initial/Reacceptance; Semiannually
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.
14.4.2* Test Methods.
14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2.
5. Batteries-general tests: Prior to conducting any battery testing, the person conducting the test shall ensure that all system software stored in volatile memory is protected from loss.
(a) Visual inspection: Batteries shall be inspected for corrosion or leakage. Tightness of connections shall be checked and ensured. If necessary, battery terminals or connections shall be cleaned and coated. Electrolyte level in lead-acid batteries shall be visually inspected.
(e) Load voltage test: With the battery charger disconnected, the terminal voltage shall be measured while supplying the maximum load required by its application. The voltage level shall not fall below the levels specified for the specific type of battery. If the voltage falls below the level specified, corrective action shall be taken and the batteries shall be retested.
6. Battery tests (specific types)
(d) Sealed lead-acid type
(2) Load voltage test: Under load, the battery shall perform in accordance with the battery
manufacturer ' s specifications.
14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
Table 14.4.5 Testing Frequencies
6. Batteries-fire alarm systems
(d) Sealed lead-acid type
6. Batteries-fire alarm systems
(d) Sealed lead-acid type
Annually
(3) Load voltage test - Initial/Reacceptance; Semiannually

Findings:

During a review of records and interview with the Director of Facilities (DOF) on 9/25/23, the FAS testing and maintenance records were reviewed.

1. At 3:42 p.m., the maintenance and testing binder for the FAS was missing records of semi-annual visual inspections for the manual pull stations and smoke detectors.

2. At 3:43 p.m. documentation was unable to be provided for the semi-annual load voltage tests for the FACP batteries. Upon interview, the DOF stated that the vendor for the FAS came out on an annual basis to test the system, but he was not aware of the requirement for semi-annual testing and inspections for FAS components.

Based on observation, document review, and interview, the facility failed to maintain the sprinkler system. This was evidenced by a sprinkler head that was corroded, and for missing documentation for monthly visual inspections to sprinkler components. This could result in a malfunction of the fire suppression system. This affected 4 of 4 patients.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7
9.7.5 Maintenance and Testing.
All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.

5.2* Inspection.
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, pain, and physical damage; and shall be installed in the correct orientation (e.g., up-right, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(2) Corrosion

5.2.4 Gauges.
5.2.4.1 *
Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
13.3.2 Inspection.
13.3.2.1.1
Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.4 System Valves.
13.4.1 Inspection of Alarm Valves.
Alarm valves shall be inspected as described in 13.4.1.1 and 13.4.1.2.
13.4.1.1 *
Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4)The retarding chamber or alarm drains are not leaking.
13.6 Backflow Prevention Assemblies.
13.6.1.1.1
Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.
13.6.1.2.1
Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.

Findings:

During a tour of the facility, review of records, and interview with the Director of Facilities (DOF) on 9/25/23, the sprinkler system was observed, and testing and maintenance records were requested and reviewed.

1. At 1:52 p.m., a side mounted fusible link sprinkler was observed in the kitchen area by the east wall with green corrosion on it. Upon interview, the DOF stated that the area where this sprinkler was located was subjected to a lot of moisture and would need to be replaced.

2. At 3:46 p.m., the monthly sprinkler component inspections logs failed to indicate if the gauges and control valves were checked. Upon interview, the DOF stated that they were written up for not having a monthly sprinkler log when the Skilled Nursing Facility (SNF) was surveyed on 5/30/23. Since then they added a log for monthly sprinkler inspections but forgot to add gauges and control valves to the list.

Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by a fire extinguisher that was not secured. This could result in damage to the fire extinguisher. This affected the limited care portion of the facility and 0 of 4 patients.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 *
Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
NFPA 10: Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3.4 * Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
1. Securely on a hanger intended for the extinguisher.
2. In the bracket supplied by the extinguisher manufacturer
3. In a listed bracket approved for such purpose
4. In cabinets or wall recesses
6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.

Findings:

During a tour of the facility and interview with the Director of Facilities (DOF) on 9/25/23, the fire extinguishers were observed.

At 1:46 p.m., an ABC type fire extinguisher was observed in the IT room stored on a shelf near the entrance. This fire extinguisher was freestanding and not anchored to a wall or mounted in place. Upon interview, the DOF stated that the IT room was not a place that the maintenance staff monitored regularly, and they did not know the fire extinguisher was placed on the shelf.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by a door with self-closing hardware that did not fully close and latch. This could result in an inability to contain a fire or prevent the spread of smoke. This affected the Rehabilitation Wing and 0 of 4 patients at the time of the survey.



Findings:

During a tour of the facility and interview with the Director of Facilities (DOF) on 9/25/23, the means of egress was observed.

At 12:09 p.m., the door to the Physical Therapy (PT) Office located in the rehabilitation wing, within the limited-care portion of the building was observed with a self-closing device. The door was tested and failed to fully close and latch. The DOF stated that the self-closing hardware probably needed to be adjusted.

Based on document review and interview, the facility failed to maintain the fire drills. This was evidenced by the failure to conduct a fire drill for every shift in every quarter of the year. This could result in the facility being unprepared during an emergency. This affected 4 of 4 patients.

Findings:

During a review of records and interview with the Director of Facilities (DOF) on 9/25/23, the fire drills were reviewed.

At 2:45 p.m., the fire drills for the second quarter (April, May, June) p.m. shift and the fourth quarter (October, November, December) a.m. and p.m. shift for 2023 were missing. Upon interview, the DOF stated that this deficiency was brought up when the Skilled Nursing Facility (SNF) was surveyed on 5/30/23. The DOF stated that enough time had not passed for them to replace the missing fire drills.

Based on document review, and interview, the facility failed to maintain the essential electrical system (EES). This was evidenced by
missing documentation for the generator testing. This could result in a malfunction of the EES. This affected 4 of 4 patients.

NFPA 101, Life Safety Code, 2012 Edition


9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition.

8.1* General.
8.1.1 The routine maintenance and operational testing program shall be based on all of the following:
(1) Manufacturer's recommendations
(2) Instruction manuals
(3) Minimum requirements of this chapter
(4) The authority having jurisdiction
8.3 Maintenance and Operational Testing.
8.3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
8.3.7.1
Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.
8.4 Operational Inspection and Testing.
8.4.1 *
EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.
8.4.1.1
If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, providing the same record as required by 8.3.4.
8.4.2 *
Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
8.4.2.1
The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.2
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.


Findings:

During a review of records and interview with the Director of Facilities (DOF) on 9/25/23, the EES testing and maintenance records were requested and reviewed.

1. At 3:18 p.m., the documentation for monthly testing of the generator batteries were missing. Upon interview, the DOF stated they were not conducting battery testing.

2. At 3:23 p.m., the 12 of 12 monthly generator load test records failed to indicate the date for when the 30 minute exercises took place. Upon interview, the DOF stated that they were using an old template that did not have a spot for them to enter the date.