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Based on observation, the facility failed to maintain the exit discharge to the public way with respect to keeping a level walking surface free of obstruction in accordance with NFPA 101, 2012 Edition, Section 7.1.6.2.

Findings Include:

During an observation on 8/20/24 at 12:27 p.m., the exit discharge to the back parking lot was inspected. The walkway was found to have multiple sections of the concrete chipped and broken. The hard-surface path to the public way cannot have more than a 1/4" variation in tread height.

Based on record review the facility failed to provide emergency lighting per NFPA 101-2012, Sections 19.2.9.1 and 7.9.3.1.1 (3) (5).

Findings include:

Review of the facility's maintenance records on 8/20/24 did not show an annual 90-minute test had been completed for the facility's emergency lighting in the last year.

Based on observations and interview, the facility failed to:

a) maintain the fire resistive properties of a two-hour barrier in accordance with NFPA 101, 2012 Edition, Section 19.1.3.3., and

b) maintain fire doors in accordance with NFPA 80, 2010 Edition, Section 4.6.4, 5.2.4.2 (3) (6) (8).

Findings include:

1. During an observation on 8/20/24 at 1:20 p.m., the two-hour wall between the hospital and the assisted living facility was inspected. There were IT wires punched through the two-hour barrier above the double doors. The penetration was not sealed with fire-resistive caulk.

2. During an observation on 8/20/24 at 1:10 p.m., the fire rated door was inspected. The door lacked fire rated hardware, and did not close and latch under the power of the self-closure. Staff member A stated the door was a fire rated door and part of the facility's fire barrier.

Based on record review, interview, and observation the facility failed to:

a) complete an annual backflow preventer test in accordance with NFPA 25, 2011 Edition, Section 13.6.2.1.,

b) maintain sufficent area area around a sprinkler head in accordance with NFPA 13, 2010 Edition, Section 8.6.5.2.1.1., and

c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3).

Findings include:

1. Record review on 8/20/24 showed the facility had not completed an annual back flow preventer test completed since 6/29/23.
During an interview on 8/20/24 at 11:30 a.m., staff member A stated he was unsure why the backflow preventer was not tested.

2. During an observation on 8/20/24 at 1:08 p.m., the walk-in cooler was inspected. There was food stored within 18 inches of a sprinkler head.

3. During an observation on 8/20/24 at 1:36 p.m., room 10A was inspected. A ceiling tile was sagging creating a gap around the sprinkler head.

Based on record review and interview the facility failed to conduct fire drills for every shift in every quarter, as well as evidence the fire drills were simulated under varied conditions in accordance with NFPA 101, 2012 Edition, sections 19.7.1.6 and 19.7.2.2.

Findings include:

1. During a review of facility fire drills on 8/20/24 it was determined the facility was missing the following fire drills:

The day and night shift in the third quarter of 2023 (July - September).
The day and night shift in the fourth quarter of 2023 (October - December).
The night shift in the first quarter of 2024 (January - March).
The night shift in the second quarter of 2024 (April - June).

During an interview on 8/20/24 at 11:10 a.m., staff member A stated the facility does not have an after action report to show the fire drills were preformed under varied conditions.

Based on record review and interview the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

Findings include:

Review of the fire safety maintenance records on 8/20/24 showed the facility lacked annual fire door assembly testing documentation.

During an interview on 8/20/24 at 11:48 a.m., staff member B stated he was not sure when the last annual fire door inspection had been completed, but he planned to do one in September of this year.

Based on record review and interview the facility failed to:

a) ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 101 2012 Edition, Section 9.1.3.1 and NFPA 110, Section 8.3.8., and

b) the facility failed to have evidence that the generator was being exercised under load 12 times a year for 30 minutes in accordance of NFPA 110 Standard for Emergency and Standby Power Systems, 2010 Edition, Sections 8.4.1 and 8.4.2.4.

Findings include:

1. Review of the emergency generator inspection records on 8/20/24 showed the last diesel fuel quality test was completed on 9/13/23, and the diesel fuel failed the test.

During an interview on 8/20/24 at 11:15 a.m., staff member B stated the next annual diesel fuel quality test is scheduled for 8/28/24.

2. Record review of diesel generator information showed there was no documentation for monthly load and annual load testing completed.

During an interview on 8/20/24 at 11:45 a.m., staff member A stated the facility did not have any documentation to show the generator had been tested 12 times a year under a 30 minute load, or that an annual load test had been completed.

Based on observation the facility failed to ensure extension cords were not used in the facility per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4.

Fndings include:

During an observation on 8/20/24 at 1:35 p.m., the employee break room was inspected. An extension cord was in use. The extension cord was being used to plug in a surge protector.