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Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 25. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 13 of 13 residents.

Findings:

During the facility tour and record review, between the hours of 9:00am to 3:30pm on 2/27/2020 it was noted:

1) That the sprinkler heads in the stairway from the business portion of the facility and the electrical room were obstructed by insulation installed around beams.

2) That the sprinkler system gauges appeared to be from 2008 and were out dated.

3) The sprinkler system had no record of a 5 year internal inspection.

4) The inspection report for 12/18/2019 identified deficiencies for unprotected areas on the second floor below this facility.

Interview with the administrator revealed the facility was not aware that the annual and quarterly inspections had not been properly conducted on the automatic sprinkler system.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 13 of 13 residents.

Findings:

During the facility tour, between the hours of 9:00am to 3:30pm on 2/28/2020 it was observed that the one hour rated fire/smoke barrier between the offices and the day room had penetrations and gaps. It was also observed that a sprinkler pipe and sprinkler head was present in the office side of the fire wall. The fire wall that enclosed the elevator lobby had penetrations and appeared to not have been completed between the stair enclosure and the rooms coming off the side patient corridor that leads to the day room.

Interview with the administrator revealed the facility was not aware of unsealed penetrations and gaps in the fire/smoke barriers.

Based on visual observation the facility failed to assure that installed fire doors were inspected and maintained. The fire doors restrict the movement of fire from one compartment to another. NFPA 80:5.2.3.5.2 states, "As a minimum, the following items shall be verified: (1) Labels are clearly visible and legible. (2) No open holes or breaks exist in surfaces of either the door or frame. (3) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (4) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (5) No parts are missing or broken. (6) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (7) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (8) If a coordinator is installed, the inactive leaf closes before the active leaf. (9) Latching hardware operates and secures the door when it is in the closed position. (10) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (11) No field modifications to the door assembly have been performed that void the label. (12) Meeting edge protection, gasketing and edge seals, where required, are inspected to verify their presence and integrity. (13) Signage affixed to a door meets the requirements listed in 4.1.4." The deficient practice had the potential to affect 13 of 13 residents.

Findings:

During the facility tour and record review, between the hours of 9:00am to 3:30pm on 2/27/2020 it was found that no documentation was provided for the annual fire door inspection. It was observed that the door closure had been removed from the door beside the elevator within the fire barrier. The central supply room door was also not provided with a door closure.

Interview with the administrator revealed the facility was not aware that the fire doors had not been properly inspected and maintained.

Based on visual observation the facility failed to assure that the generator was provided with a remote annunciator that is storage battery powered to operate outside the generating room in a location readily observed by operating personnel in accordance with NFPA 99. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 13 of 13 residents.

Findings:

During the facility tour, between the hours of 9:00am to 3:30pm on 2/27/2020 it was observed that the generator was not provided with a remote annunciator.


Interview with the administrator revealed the facility was not aware of the requirement of a remote annunciator hard-wired to indicate alarm conditions of the emergency power source.

Based on record review the facility failed to assure that proper testing/inspections were being performed on the receptacle in patient care rooms and being documented. Receptacles in patient care rooms shall be inspected as per NFPA 99:6.3.3.2 and documented as per NFPA 99:6.3.4.2. This deficient practice could potentially affect 13 of 13 residents.


Findings:

During record review, between the hours of 9:00am to 3:30pm it was noted that no documentation was provided for the testing and inspections performed on the receptacles in patient care rooms and/or that the testing and inspections had been performed.

Interview with the administrator revealed the facility was not aware that receptacles in the patient care rooms had not been inspected and/or tested.