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

Egress door has two locking devices on them.

19.2.2.2.6Doors that are located in the means of egress and arepermitted to be locked under other provisions of 19.2.2.2.5 shallcomply with all of the following:
(1) Provisions shall be made for the rapid removal of occu-pants by means of one of the following:(a) Remote control of locks(b) Keying of all locks to keys carried by staff at all times(c) Other such reliable means available to the staff at alltimes
(2) Only one locking device shall be permitted on each door.
(3) More than one lock shall be permitted on each door, sub-ject to approval of the authority having jurisdiction.

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, staff interview and record review during the course of the survey it was determined the facility failed to maintain emergency exit signs in accordance with NFPA 101, section 19.2.10, 7.10. The following evidenced this:

Non listed self luminous signs in use throughout the facility.

7.10.4* Power Source.

Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 43 for individual occupancies, the signs, other than approved self-luminous signs and listed photoluminescent signs in accordance with 7.10.7.2, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, NFPA 96 and 17A. This was evidenced by:

1. Past due hydro on hood suppression tank. Last done in 2009. Kitchen hood system.
2. Class K portable fire extinguisher placard does not have the correct verbiage for instruction/use.
3. Deficiency on the hood suppression report. Penetration through fire wall.
4. No wheel chocks or restraints on the stove in the kitchen.

1. Life Safety Code Section 9.2.3 commercial cooking equipment to comply with NFPA 96. NFPA 96, section
10.2.6. 10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

NFPA 17A section 7.5 Hydrostatic testing. 7.5.1 The following parts of the wet chemical extinguisher systems shall be subjected to a hydrostatic pressure test at intervals not exceeding 12 years: (1) Wet chemical containers (2) Auxiliary pressure containers (3) Hose assemblies.

2. Life Safety Code Section 19.3.2.5 to comply with Section 9.2.3. Commercial cooking equipment in accordance with NFPA 96, Section 10.2.2, in part, a placard near each extinguisher must state that the fire protection system shall be activated prior to using the fire extinguisher.

3. 5.1.4*Internal hood joints, seams, filter support frames, andappurtenances attached inside the hood shall be sealed orotherwise made greasetight.

4. ) Kitchen cooking appliances were not provided with an approved method to ensure the appliances were returned to the correct design location below the fixed extinguishing system nozzles, as required.

The commercial cooking equipment deficiency has the potential to affect all staff in the kitchen including all smoke compartments; 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 protection requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by:

1) No documentation of semi-annual fire alarm inspection reports was available during time of inspection.

2) Fire alarm annual report has different amount of smoke dampers and does not appear that all of them are being tested.

Life Safety Code section 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 section 14.4.5 requires, in part, testing shall be performed in accordance with the schedules in Table 14.4.5.

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.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25. This was evidenced by:

1) Pressure gauge for the suppression system over five years old.

2) Two quarterly and semi an nual reports not available.

3) Escutcheon missing in CT closet.

4) ) No documentation of internal pipe obstruction test conducted within the last five years.

1. NFPA 25 section 5.3.2.1, "Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge."

2. Life Safety Code Section 19.3.5.1 to comply with section 9.7. Section 9.7.5 maintenance and testing to comply with NFPA 25. NFPA 25 section 5.1.1.2 requires, in part, testing and maintenance frequencies shall be determined by Table 5.1.1.2.

3. 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.

4. NFPA 25 section 14.2.1, in part, inspection of piping and branch line conditions shall be inspected every 5 years for the purpose of inspecting for the presence of foreign organic and inorganic material.

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 facility administrator and maintenance director during the exit conference.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 10 as evidenced by:

Fire extinguishers were sitting on the floor.

NFPA 101 Life Safety Code 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in.

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

Through observation during documentation review, it was determined that the facility failed to meet the building services requirements in accordance with NFPA 101, 80, 90A, and 105. This was evidenced by:

1) Four-year fire/smoke damper testing and inspection report was unavailable at time of survey.

2) Fire dampers were no longer accessible.

Life Safety Code section 19.5.2.1 to comply with section 9.2. Section 9.2 to comply with NFPA 90A
NFPA 90A section 5.4.8 to comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
NFPA 80 section 19.4 Periodic Inspection and Testing
NFPA 105 section 6.5 Periodic Inspection and Testing

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.

Through observation during the survey, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 101 and NFPA 99. This was evidenced by:

1) No documentation for medical gas annual inspections and testing

NFPA 99 section 5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.
This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the effected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator 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 load bank test

2) No documentation of annual fuel quality test

1. 8.4.2.3Diesel-powered EPS installations that do not meet therequirements of 8.4.2 shall be exercised monthly with the avail-able EPSS load and shall be exercised annually with supplemen-tal loads at not less than 50 percent of the EPS nameplate kWrating for 30 continuous minutes and at not less than 75 percentof the EPS nameplate kW rating for 1 continuous hour for a totaltest duration of not less than 1.5 continuous hours.

2. 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.