Every finding on record at Southwest General Health Center

Based on observations and interviews the facility failed to ensure exit accesses are in accordance with the LSC, 2012 Edition Sections 7.1.10.1, 7.7.3.4. and 19.2.2.5.3. This deficient practice had the potential to affect all 10 patients who reside within the facility. Findings include: Observations during the tour with the Director of Maintenance (DM) on 02/24/25 located emergency exit discharges not maintained properly. At 9:16 A.M. the egress discharge north walkway was obstructed by temporary electrical equipment places on the sidewalk by the exterior transfer switch. At 9:33 A.M. both exit doors next to the central meeting area fireplace were found inoperable and unable to open and or function, as designed. Interview with the Director of Maintenance verified the above findings at the time of the observation.

Based on observation and staff interview, the facility failed to ensure kitchen fire suppression system was maintained in accordance with NFPA 101 – 2012 Edition, Section 9.2.3 and NFPA 96 – 2011 Edition Sections 10.2.6, 11.2, 13.2.3; NFPA 17A 2009 Edition 5.6.4; This deficient practice had the potential to affect all 10 patients who reside within the facility. Findings include: Observation on 02/24/25 at 9:35 A.M. during tour of the facility with the Director of Maintenance (DM), noted that the wheeled appliances located under the kitchen suppression systems were not provided with floor marking or chock to align with the nozzles to provide protection by the suppression system when moved for cleaning or service. The movable appliances were not provided with a chain or restraint to prevent over-extension of the gas line. The appliance was a new unit consisting of four burners and a skillet area, however, only one suppression nozzle was in place where each require their own coverage nozzle, which resulted improper fire supression protection. Interview with the DM verified the findings at the time of observation.

Based on observation, record review, and staff interview the facility failed to ensure sprinklers were inspected quarterly to ensure system integrity in accordance with NFPA 101 – 2012 Edition 9.7.5 through 9.7.8 and NFPA 25 – 2011 Edition Section 5.1 to 5.2.1.4. This deficient practice had the potential to affect all 10 patients who reside within the facility. Findings include: Observation on 02/24/25 at 9:29 A.M. in the south mechanical room found a recessed sprinkler head cover that had been attached to the ceiling and unable to drop free in the event of a fire. Further observation at 9:47 A.M. of the sprinkler head spare cabinet identified only four spare sprinkler heads in the sprinkler room supply box and not the required six sprinkler heads, per the applicable code. Record review on 02/24/25 at 11:12 A.M. noted no sprinkler inspection was completed for the first quarter (January, February and March) of 2024. Interview with the Director of Maintenance verified the finding at the time of observation and review.

Based on review of facility fire drill documentation and staff interview, the facility failed to conduct quarterly fire drills in accordance with NFPA 101-2012 Edition, Section 19.7.1. This deficient practice had the potential to affect all 10 patients who reside within the facility. Findings include: On 02/24/25 at 1:20 P.M., review of the last twelve months of the fire drill documentation with the Director of Maintenance (DM) indicated drills were not complete, as required by the applicable code. The facility was unable to produce a fire drill record for the months of January through May and August through December. No additional documentation was provided at the time survey to validate the fire drills were performed in accordance to the applicable code. Interview with the DM verified the findings at the time of the review.

Based on record review, observation and interview, the facility failed to ensure life safety from fire. --- See L824

Based on record review, observation and interview, the facility failed to ensure life safety from fire. This had the potential to affect all patients. --- See Life Safety Code Survey Report