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Through observation and discussion during the tour of the facility, it was determined the facility failed to maintain fire rated doors per NFPA 101 2012 Edition Chapter 8 Section 8.3.3 paragraph 8.3.4.4. Failure to maintain fire rated door and assemblies in hazardous areas has the potential to harm all resident ' s, staff and visitor in the building if the fire rated doors failed to operate if a fire was to occur. This was evidence by the following.

The Gift Shop is over 50 square feet in area and is considered as a hazardous area containing combustible storage, the self-closing device was disconnected from the door.

The Director of Maintenance acknowledged the hazardous area enclosures and door condition during a tour of the facility.

Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.

Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.

(a) Fire Department Connection has no identification posted as required per NFPA 13 Each
fire department connection to sprinkler systems shall be designated by a sign having raised or engraved letters at least 1 in. (25.4 mm) in height on plate or fitting.
(b) One (1) painted sprinkler head in resident ' s room 436. Per NFPA 13 section 3-2.6.3 "Unless applied by the manufacturer, sprinkler shall not be painted.
(c) Sprikler escutcheon plate is missing in basement hall. Per NFPA 13 section 3-2.7.2.
(d) Two (2) pendent sprinkler heads are spaced within 4 feet of each other in the conference room. Per NFPA 13 section 8.5.3.4
A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers.

The Maintenance Director acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observation and staff interview during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 19.3.6.2.2. This deficient practice could affect all residents in the smoke compartment by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

Smoke barrier wall penetrations were not sealed to maintain the 30-minute fire resistance rating of the smoke barrier, as required. The basement Electrical room smoke barrier wall was observed to have unsealed wall penetrations.

The Maintenance Director acknowledge the penetrations during a tour of the facility.

Life Safety Code 101 section 8.4.4.1 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a smoke partition shall be protected by a system or material that is capable of limiting the transfer of smoke.

Based on record review and discussion with staff during the course of the survey, it was determined that the facility failed to contain all required elements of the fire safety plan in accordance with the Life Safety Code, Section 19.7.2 and 19.7.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. This was evidenced by the following:
During review of the facility records, with the Maintenance Director, the facilities fire safety plan failed to contain the elements of the;
(a) Transmission of the alarm to the fire department.
(b) Preparation for building evacuation.

The Maintenance Director acknowledge the lack of required elements of the fire safety plan during record review.

Life Safety Code 101 section, 19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect all residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:

Fire drills are required to be conducted under varying conductions. Time of shifts is one of the conductions. Each shift is 8.5 hours long. Drills were conducted with in a 30-minute time frame from April, 2016 through April, 2017.
(a) 1st shift-two out of four fire drills in the past year were conducted at the same time 13:45 hrs.
(b) 2nd shift-three out of four fire drills in the past year were conducted at 17:30 and 18:00 hrs.

The Maintenance Director acknowledge the conditions of fire drills deficiency during record review of the facility.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.