LIFE CARE CENTER OF NORTH GLENDALE

Egress Doors 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: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with

Based on observation the facility failed to maintain two special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only." Findings include: Observations made while on tour on July 5, 2023, revealed the following; 1) the rehabilitation room door #1 delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 45 lbft for the left door and 20 lbft for the right door 2) the rehabilitation room door #2 delayed egress door exit door failed to open with a force of less than 15 lbft. The panic bar was pushed and and set off the irreversible process at 30 lbft for the left door and 70+ lbft for the right door. The left door took 55lbft to open the door to the public way During the exit conference on July 5, 2023, the above findings were again acknowledged by the management team.

Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Based on observation behind the kitchen cook top rags were seen on the gas line and floor. Failing to inspect and clean the kitchen hood baffles from cleaning rags, oil, grease will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and/or staff. Findings include: NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 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.... Chapter 11, Section 11.2 Inspection and Testing, and Maintenance of Fire extinguishing Systems. Section 11.6 Cleaning of Exhaust Systems. Upon inspection, if the exhaust system is found to contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction. Section 11.6.2* Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to remove combustible contaminants prior to the surfaces becoming heavily contaminated with grease or oily sludge. Observations made while on tour on July 5, 2023, revealed three (3) cleaning rags behind the cook top. Two (2) cleaning rags were on the main gas line to the cook top and the third was on the floor. Staff said the rags appeared to have been from the hood cleaning company. The last hood cleaning was in May 2023. During the exit conference on July 5, 2023, the above findings were again acknowledged by the management team.

Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff. NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." Findings include: Observations made while on tour on July 5, 2023, the following; 1) 3rd floor "C" hall rated door, failed to latch secure 2) 3rd floor fireplace lounge, rated door failed to latch secure 3) 2nd floor "A" hall rated door, failed to latch secure 4) room 207 failed to latch secure 5) 2nd floor soiled linen rated door, failed to latch secure 6) 2nd floor "C" hall rated door, failed to latch secure 7) room 232 rated door, failed to latch secure 8) room 101 had excessive gap, 1/2 inch on the lower handle side of the door 9) the door between the kitchen and laundry in the service hall failed to latch secure. During the exit conference conducted on July 5, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to ensure a protected covering over exposed wires. Failure to have the appropriate protection around exposed wires could cause harm to patients and/or staff. . NFPA 101, 2012 Edition Chapter 19. "19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1" " 9.1 Utilities. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface." Findings include: Observations made while on tour on July 5, 2023, revealed exposed electrical wiring under the disposal in the kitchen. Two (2) flex conduit were seen, pulled away from the disposal. The exposed wiring was approximately shin height. During the exit conference on July 5, 2023, the above findings were again acknowledged by the management staff. .