Every finding on record at Hopewest

Based on observation and staff interview during the survey on May 18, 2022, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times in accordance with Life Safety Code 101 Section 19.2.1, 7.2.1.5.4. This deficient practice could affect all residents, staff and visitors within the facility if the Means of Egress is not maintained throughout the facility. This was evidenced by the following: 1) Stair well needs proper signage to differentiate egress from roof access. This deficiency affected the occupants of all associated smoke compartments, including residents, staff and visitors and was discussed the Facility Administrator and the Maintenance Director during the exit conference.

During the review of the facility records, with the staff on May 18, 2022, kitchen appliances not maintained in accordance with NFPA 96. The following evidenced this: 1) Kitchen appliances not equipped with floor cleats to ensure proper placement. The Cooking Facilities deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. The maintenance director acknowledge the lack of cleaning and inspection of the system during record review.

Based on record review, observation and staff interview during the course of the survey conducted on May 18, 2022, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101, section 19.3.5.1, 9.7, 9.7.5, NFPA 25 and NFPA 13. The following evidenced this: 1) Fire sprinkler heads noted throughout to be loaded with dust/debris. The fire sprinkler deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference. NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observation and staff interview during the course of the survey conducted on May 18, 2022, it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 19.3.7.3 including 8.5. The following evidenced this: 1) Multiple penetrations above ceiling in kitchen/restaurant corridor. Maintenance director acknowledged the deficiency during a tour of the facility. The smoke barrier deficiency has the potential to affect all occupants, who might include staff and visitors in associated compartments; items were discussed during the survey and again during the exit conference. Life Safety Code Section 19.3.7.3, in part, smoke barrier walls constructed in accordance with Section 8.5 with a minimum of 1/2-hour fire resistive rating. Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

Based on record review and staff interview during the survey, May 18, 2022, it was determined the facility failed to conduct fire drills in accordance with NFPA 101, 19.7.1. The following evidenced this: 1) Fire drills were not conducted at "varied times". The fire drill deficiencies have the potential to affect all occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference. Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.