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Based on observation during the survey, conducted on January 30&31, 2018, it was determined the facility failed to install and maintain the fire alarm system in accordance with NFPA 101, section 19.3.4, 19.3.4.5, and 9.6, including NFPA 72 National Fire Alarm Code. The following evidenced this:

1) Multiple smoke detectors throughout have been installed within 3 feet of a return or supply diffuser

NFPA 72, 17.7.4.1* In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the
detectors.

The fire alarm deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within all smoke compartments; items were discussed during the survey and again during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

1. Penetration through 1 hour smoke barrier by room 110.
2. Penetration in electrical room.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the building services for gas equipment in accordance with NFPA 101, 19.5, 19.5.1.1, 9.1.1, including NFPA 54, National Fuel Gas Code. The following evidenced this:

1) Main laundry room has four (4) Type 2 dryers rated at an elevation between 0-2000 ft., verified by reviewing manufactures rating label on the back of each unit.

NFPA 54, section 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft. (600 m) shall be reduced in accordance with one of the following methods:

(1) At the rate of 4 percent for each 1000 ft. (300 m) above sea level before selecting appropriately sized appliance
(2) As permitted by the authority having jurisdiction
(3) In accordance with the manufacturer's installation instructions

The building service deficiencies has the potential to affect all room occupants, who might include staff, residents and visitors within this smoke compartment; items were discussed during the survey and again during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 99 and NFPA 110. This was evidenced by:

1) No documentation of annual fuel quality test

NFPA 110. NFPA 110, Section 8.3.8 a fuel quality test shall be performed at least annually using approved ASTM standards.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed control the transfilling of oxygen in accordance with National Fire Protection Association (NFPA) 99- Health Care Facilities (2012). This was evidenced by the following:

Flammable materials were stored in the transfil room.

11.3.5.3 Oxidizing gases suych as oxygen and nitrous oxide shall be seperated from combustaibles or falmmable materials by one of the following:
(1) Minimum distance of 6.1 m (20)

The transfilling of cylinders' deficiency affects 1 transfilling room within affected smoke compartments; item was discussed during the survey and again during the exit conference.