Acacia Health Center

Based on observation and staff interviews, the facility failed to ensure the electrical breaker for the fire alarm system has visual markings to distinguish it from other breakers. Failure to properly identify/mark the fire alarm system could lead to the harm of residents and staff in an emergency. NFPA 101 - 2012 Edition, Section 18.3.4.5.1, Detection systems, where required, shall be in accordance with 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, 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. NFPA 72-2010 Edition, Section 10.5.5.2. For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT." Findings include: Observations made in the electrical room on December 10, 2024, revealed the electrical breaker for the fire alarm system did not have visual markings to distinguish it from other breakers. During the exit conference on December 10, 2024, the management team confirmed that the electrical breaker for the fire alarm system did not have visual markings to distinguish it from other breakers.

Based on observations the facility failed to repair the patient sleeping room corridor doors. Failing to protect patient sleeping rooms from heat or smoke will cause harm to 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 December 10, 2024, revealed the following; 1) room 223 door had an excessive gap on the upper handle side of the door, light can be seen from inside the room when the door is closed 2) room 16233 door not latching 3) room 347 door had an excessive gap on the upper handle side, light can be seen from inside the room when the door is closed 4) room 349 door had an excessive gap on the upper handle side of the door, light can be seen from inside the room when the door is closed 5) third-floor 90-minute door outside dining room missing strike plate. During the facility tour and exit conference conducted on December 10, 2024, the above findings were again acknowledged by the management team.