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Based on observation and interview, the facility failed to maintain an emergency release switch for the full time magnetic locks on the Geriatric Wing per the requirements of:

2012 NFPA 101, 19.2.2.2.5.2 (1), and 19.2.2.2.6

This deficiency could affect 25 occupants.

Findings include:

On 05/08/2019, during a tour of the facility from 9:00 am to 2:00 pm, the surveyor observed all of the full time magnetic locked doors on the Geriatric Wing failed to automatically unlock upon activation of the emergency release switch, but did release under key pad:

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 9.6.1.3
2010 NFPA 72, 18.5.4.4.7, and 21.9

This deficiency could affect 25 occupants.

Findings include:

On 05/08/2019, during a tour of the facility from 9:00 am to 2:00 pm, the surveyors observed the following:
1. Three visual fire alarm notification devices in the field of view not flashing in synchronization near the Nurses' Station in the Geriatric Hall during activation of fire alarm system.


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2. All of the full time magnetic locked doors on the Geriatric Wing failed to automatically unlock upon the following, but did release under key pad:
a. Activation of the fire alarm system.
b. Loss of primary power to the fire alarm system

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, review of documentation and interview, the facility failed to maintain the automatic sprinklers per requirements of:

2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.3.1.1.1.6

Findings include:

On 05/08/2019, during a tour of the facility from 9:00 am to 2:00 pm, the facility failed to provide documentation that the dry sprinklers installed in 2003, located in the walk in freezer had been replaced or a representative sample tested within 10 years of installation.

A member of the maintenance staff and administrator was present, when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to maintain the dampers (smoke/fire/ceiling) per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2010 NFPA 80, 19.4, and 19.5
2010 NFPA 90A, 5.4.8.1, and 5.4.8.2
2010 NFPA 80, 19.4.1.1
2010 NFPA 105, 6.5.2

This deficiency could affect all occupants.

Findings include:

On 05/08/2019, during a tour of the facility from 9:00 am to 2:00 pm, the facility failed to provide documentation of testing the dampers (smoke/fire/ceiling) within the past 6 years.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to prohibit portable space heating devices per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency could affect 1 of 7 smoke compartments.

Findings include:

On 05/08/2019, during a tour of the facility from 9:00 am to 2:00 pm, the surveyor observed a portable space heating device in use in the Admission Office on Administration Hallway. The facility failed to provide documentation that the heating element for this device did not exceed 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to maintain the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.8, 8.4.1, 8.4.2, and 8.4.2.3

Findings include:

On 05/08/2019, during a tour of the facility from 9:00 am to 2:00 pm, the facility failed to provide documentation on the following:

1. The testing of the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate kW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

2. To have a fuel quality test performed at least annually using tests approved by ASTM standards.

A member of the maintenance staff was present when this deficiency was identified.