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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 19 of 19 residents.

Findings:

During the facility tour on 8/8/2024, between the hours of 11:00 am to 5:30 pm it was observed that above the fire exit hardware on both stairs for the third, fourth, and fifth floor had double sided key deadbolts installed above the fire exit hardware. It was also observed that the smoking area had a gate that appeared to be provided with a lock that had netting installed over and attached to it. The other side had overgrown foliage preventing use of the gate.

Interview with the maintenance supervisor revealed the facility was not aware that the additional lock not connected to the fire exit hardware was not allowed.

Based on visual observation the facility failed to assure that the smokeproof enclosure meets the requirements of NFPA 101:7.2.3.2 . This reduces or eliminates the potential of fire and/or smoke spreading from one floor to another. This deficiency has the potential to affect 19 of 19 residents.

Findings:

During the facility tour on 8/8/2024, between the hours of 11:00 am to 5:30 pm that the tops of the smoke-proof enclosures had a device with a fusible link. There was no documentation that the device had received it's required inspection.

Interview with the maintenance supervisor revealed the facility was not aware that the device required an inspection.

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 19 residents.


Findings:

During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that the rooms on the opposite side from medical records had rooms converted to storage for patient records in numerous large cardboard boxes. One room was also being used for an additional maintenance/repair room. These areas are now hazardous and require separation with smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing.

Interview with the maintenance supervisor revealed the facility was not aware of the hazardous areas created and that they needed self closing doors.

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 25:5.1.1.2 states, " Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance."

Findings:

During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was noted that the sprinkler system was yellow tagged on 7/30/2024 due to the FDC hydro test failing. It was also observed that the sprinkler head in room 401 appeared to be damaged. It was also found that the person that performed the testing/inspection on the sprinkler system for the original yellow tag was not licensed.

Interview with the maintenance supervisor revealed the facility was not aware that the sprinkler head was damaged. He was aware that the FDC hydro test had failed and that the bid had been approved for the repair.

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 19 of 19 residents.

Findings:

During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that the corridor walls had gaps and numerous openings both above and below the drop ceiling. In multiple areas penetrations had been made for extension cords and/or surge protectors to be utilized in other spaces such as the nursing, med room, electrical/phone room, office, and Dr. Office on the 4th floor.

Interview with the maintenance supervisor 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. 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 19 of 19 residents.

Findings:

During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that the corridors are being used for supply/return air plenum. The HVAC closet has louvers that are open to the corridor.

Interview with maintenance supervisor revealed the facility was not aware the HVAC system was using the corridors as a return/supply air plenum.

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 6 of 19 residents.

Findings:

During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that the smoking area on the first floor was not provided with metal containers that had self-closing cover devices into which ashtrays could be emptied into. Cigarette butts were scattered all around the smoking area in the vegetation. It appeared the previous metal container that was on or near the wall based off the signage had been removed.

Interview with the maintenance supervisor revealed the facility was not aware the containers in the smoke area did not meet the requirements and/or had been removed.

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 19 of 19 residents.

Findings:

During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm documentation was provided that an annual fire door inspection was performed on 5/28/2024. However on the 1st floor, the fire door between the lobby leading to the stairs and maintenance has open screw holes through the door and the label painted over. The maintenance room door is missing screws. The fire doors for the stairs on the 3rd, 4th, and 5th floor have double sided deadbolts that are not rated to be installed on fire-rated door assemblies. Room 509 had the door unable to close due to dragging the floor.

Interview with the maintenance supervisor 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 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 of residents.

Findings:

During the facility tour on 8/8/2024, between the hours of 11:00am to 5:30pm it was observed that throughout the facility extension cords and surge protectors were being used in the place of permanent fixed wiring. Extension cords and surge protectors were going through walls and drop ceilings in numerous areas including the nursing station, med room, electrical/phone room, office, and Dr. Office on the 4th floor. Surge protectors were also being used for high voltage appliances such as microwaves, coffee appliances, and full size refrigerators. On the 5th floor a surge protector had been tapped to the receptacle due to the surge protector plug and outlet being damaged in the medicine room.


Interview with the maintenance supervisor 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.