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Based on record review, observation and interview the facility failed to ensure the was a fire alarm system was maintained in accordance with the LSC, 2012 Edition 9.6.1, 9.6.2 and 9.6.3. This deficient practice had the potential to affect all 9 residents.

Findings include:

During the record review with the Director of Maintenance (DM) on 07/24/24 at 10:30 A.M. revealed the fire alarm system not being maintained, as required. The documentation provided did not show a semi-annual visual inspection had been completed. No additional documentation was provided by the time of exit to validate the fire alarm system was tested and inspection every six months.

Observation on 07/25/24 at 9:00 A.M. found the fire alarm panel had a trouble signal due to a ground fault.

Interview with the DM verified the finding at the time of the review.

Based on record review, observations and interviews the facility failed to ensure that all sprinklers are properly maintained in accordance with the NFPA 101 19.3.5.3 and NFPA 25, 4.3, 4.3.1, 4.6.12, 4.6.12.1, 9.7.5, 9.7.6, 9.7.7, 9.7.8 and 13.4.4.2.9. This deficient practice had the potential to affect all nine residents.

Findings include:

Record review with the Director of Maintenance (DM) on 07/24/24 between 9:00 A. M and 1:00 P.M. noted the sprinkler inspection and test records. Further review revealed sprinkler testing was not completed as required in the following areas:

" Records provided did not document the three year air leak test requirement of all dry sprinkler systems as noted in the contractor quarterly inspection report.
" The fire department connection (FDC) five year hydrostatic test was not available for review.
" No records to indicate the weekly air pressure recordings or the monthly water pressure recordings were complete.


Observations during the tour of the facility on 07/25/24 found the following deficiencies:
" At 9:30 A.M. wires and data cables were found attached to the sprinkler piping in the storage room across from the maintenance shop.
" At 11:51 P.M. the FDC by the Respiratory Entrance has bushes planted in front of it, which obstructed the access to the connection, in the event of a fire.

Interview with the DM verified the finding at the time of discovery.

Based on observation and staff interview, the facility failed to ensure fire/smoke barriers were maintained in accordance with NFPA 101 - 2012 Edition, Section 8.3.5 . This deficient practice had the potential to affect all nine residents.

Findings include:

Observations during the tour with the Director of Maintenance (DM) on 07/29/24 revealed improperly sealed penetrations in the following locations:

" At 9:58 A.M. the smoke barrier wall for the oncology storage room was found to have unsealed penetrations around HVAC and conduits.
" At 10:27 A.M. the wall above the rolling fire door from the main lobby to the atrium was found to have unsealed penetrations along the top of the door frame, around the HVAC between the brick and the concrete wall and around the pipes and conduits.
" At 10:35 A.M. the wall between the ER and CAT scan had unsealed penetrations around conduit above the vending machines.
" At 10:44 A.M. the wall in the respiratory corridor had unsealed penetrations around conduits.
" At 10:53 A.M. the wall around the stairwell by the surgery lobby was not sealed to the roof deck.
" At 11:27 A.M. unsealed penetrations were found around conduits at the B level atrium wall.
" At 11:32 A.M. the wall above the door from the café to the atrium had unsealed penetrations around conduits.
" At 11:39 A.M. the wall above the door to the housekeeping ramp had unsealed penetration.
" At 11:48 A.M. unsealed penetrations were found above the stairwell door by the old boiler room.


Interview with the DM verified the finding at the time of observation.

Based on observation and interviews the facility failed to ensure smoke barriers were maintained in accordance with NFPA 101 - 2012 Edition, Section 19.3.7.6, section 8.5.4, and NFPA 80 2010 Edition Section 4.2. This deficient practice had the potential to affect all nine residents.

Findings include:

Observations during the tour of the facility with the Director of Maintenance (DM) on 07/24/24 2 revealed the fire doors were not maintained properly in the following locations:

" At 2:56 P.M. elevator equipment Room C did not latch to the frame.
" At 3:46 P.M. the double door by the café did not latch to the frame
" At 3:50 P.M. the smoke doors from the atrium to the café had a gap in excess of 1/8" between the doors,
" At 4:04 P.M. the double corridor doors by the kitchen did not latch to the frame.

Interview with the DM verified the finding at the time of observation.

Based on observations and staff interview, the facility failed to ensure the electrical panels were readily and safely accessible in accordance with NFPA 101-2012 Edition, Section 19.5.1.1, 9.1, and NFPA 70-2011 Edition, Section 110.26. This deficient practice had the potential to affect all nine residents.

Findings include:

Observations during tour of the facility with the Director of Maintenance (DM) on 07/25/24 at revealed electrical panels not being maintained properly in the following locations:

" At 9:30 A.M. the main storage room had boxes stored within three feet of the electrical panels.
" At 9:44 A.M. the dietary storage room had boxes stored within three feet of the electrical panels.
" At 9:50 A.M. the electrical panels behind the laundry was blocked by storage.


Interview with the DM verified the finding at the time of observation.

Based on observations, record review, and staff interview the facility failed to ensure fire dampers were maintained in accordance with NFPA 101 2012 Edition section 19.5.2, NFPA 90 A-2012 Edition, Section 5.4.8, and NFPA 80-2010 Edition, Section 19.4. This deficient practice had the potential to affect all nine residents.

Findings include:

Record review on 07/24/24 at 11:00 A.M. noted the facility inspection and test records from the previous 24 months. Further review revealed the documentation lacked a fire damper inspection within the past six years. The last report fire damper inspection was completed in 2016. No additional documentation was provided to validate the dampers were inspected.

Interview with the Director of Maintenance verified the finding at the time of review.

Based on record review, observation, and staff interview the facility failed to ensure fire door assemblies were annually inspected, tested, and maintained in accordance with NFPA 101 - 2012 edition Section 7.2.1.15, 8.5.4, NFPA 80 5.2.4, and NFPA 105 - 2010 Edition Section 4.1.1 and 5.2.1. This deficient practice had the potential to affect all nine residents.

Findings include:

Record review on 07/24/24 between 9:00 A.M. to 1:00 P.M. noted the facility inspection and test records from the previous 12 months. Further review revealed no record of fire doors being inspected and tested. No additional documentation was provided at the time of survey to validate the inspections were completed.


Interview with the Director of Maintenance verified the finding at the time of review.

Based on record review and interview the facility failed to ensure the emergency generator is exercised monthly under load for 30 minutes in accordance with the LSC, 2012 Edition 8.3.1 through 8.3.4 and 8.4.1 through 8.4.2.3. This deficient practice had the potential to affect all nine residents.

Findings include:

Record review on 07/24/24 at 12:30 P.M. during the generator record review with the Director of Maintenance (DM) revealed the diesel generator monthly operational testing was not done properly. The monthly run test of the generator did indicate what the load was. The facility had no record of the 36 month load bank test had been performed.

Interview with the DM verified the finding at the time of observation.