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Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) plan. This was evidenced by the failure to provide policy and procedure for a medical documentation. This affected one of one patients, and could result in an ineffective EP plan.

Findings:

During document review and interview with the Emergency Preparedness Staff on 6/17/25, the EP policies and procedures were requested and reviewed.

At 2:20 p.m., the facility failed to provide upon request a policy and procedure outlining the facility's medical record documentation system to preserve patient information, protect confidentiality of patient information, and secure and maintain availability of records in the event of an emergency. Upon interview, the Emergency Preparedness Staff confirmed the Policy and Procedure was not available for review.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) Plan. This was evidenced by the failure to provide a communication plan that included current contact information for entities providing services under arrangement. This could result in the lack of notification to entities providing services under arrangement, and affected one of one patients.

Findings:

During document review and interview with Emergency Preparedness Staff on 6/17/25, the EP communication plan was requested and reviewed.

At 2:22 p.m., a review of the facility's EP plan revealed that the facility failed to include the name and contact information for the Fire Alarm System, Sprinkler System, and generator maintenance vendors. Upon interview, the Emergency Preparedness Staff stated that he was not aware that the contact information was missing from the EP.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) Plan. This was evidenced by the failure to provide a communications plan with the facility's method for sharing information. This affected one of one patients, and could result in ineffective emergency planning.

Findings:

During document review and interview with the Emergency Preparedness Staff on 6/17/25, the EP plan was requested and reviewed.

At 2:24 p.m., a review of the EP revealed that the facility's communication plan failed to provide a communications plan with the facility's method for sharing information and medical documentation for patients, as necessary, with other health providers, to maintain the continuity of care. Upon interview, the Emergency Preparedness Staff confirmed that the policy was missing.

Based on document review and interview, the facility failed to maintain the Emergency Preparedness (EP) Plan. This was evidenced by the failure to provide an updated communications plan that included a means of providing information to the authority having jurisdiction. This affected one of one patients, and could result in ineffective emergency planning.

Findings:

During document review and interview with the Emergency Preparedness Staff on 6/17/25, the EP plan was requested and reviewed.

At 2:26 p.m., the facility failed provide an updated communications plan that included a means of providing information about the facility's needs, and its ability to provide assistance to the authority having jurisdiction, the incident command center, or designee. Upon interview, the Emergency Preparedness Staff stated that the policy could not be found.

Based on observation and interview, the facility failed to maintain the building construction. This was evidenced by unsealed penetrations. This affected one of one smoke compartments and one of one patients, and could result in the spread of fire and smoke.

Findings:

During a tour of the facility and interview with Maintenance Staff on 6/17/25, the ceiling and walls were observed.

1. At 10:15 a.m., an unsealed penetration approximately one by one inch was observed on the ceiling of the emergency room area with a conduit running through. The penetration failed to be properly fire stopped. Upon interview, the Maintenance Staff stated that he was unaware of the unsealed penetration.

2. At 10:18 a.m., an unsealed penetration approximately one by one inch was observed on the ceiling of the kitchen area with a conduit running through. The penetration failed to be properly fire stopped. Upon interview, the Maintenance Staff stated that he was unaware of the unsealed penetration.

Based on record review and interview, the facility failed to maintain the cooking facility. This was evidenced by the failure to perform one of two semi-annual kitchen hood inspection during the past year. This affected one of one smoke compartments and one of one patients, and could result in an ineffective fixed fire suppression system in the kitchen area.

NFPA 101 Life Safety Code, 2012 edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition.
11.7. Cooking Equipment Maintenance.
11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.
10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(4) NFPA 17A

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 edition.
7.3.3* At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual.
7.3.3.1 Maintenance shall include the following:
(1) A check to see that the hazard has not changed.
(2) An examination of all detectors, the expellant gas container(s), the agent container(s), releasing devices, piping, hose assemblies, nozzles, signals, all auxiliary equipment, and the liquid level of all nonpressurized wet chemical containers.
(3)*Verification that the agent distribution piping is not obstructed.

Findings:

During document review and interview with Maintenance Staff on 6/17/25, the semi-annual kitchen hood documentation was requested and reviewed.

At 10:19 a.m., the facility failed to provide upon request one of two semiannual inspection and test documentation for the kitchen hood fire suppression system. The last semi-annual kitchen hood inspection was performed was on 6/22/24 according to the inspection report and inspection tag. Upon interview, the Maintenance staff explained that the facility had a difficult time having an inspector service the kitchen hood fire suppression system due to the isolated location of the facility.

Based on document review and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to perform the semi-annual FAS inspection and the failure to perform the smoke detector sensitivity testing. This affected one of one patients and one of one smoke compartments, and could result in a non-detected system malfunction in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.
Table 14.3.1 Visual Inspection Frequencies-semiannually
3. Batteries
4. Transient suppressors
5. Fire alarm control unit trouble signals
7. In- building fire emergency voice/alarm communications equipment
8. Remote annunciators
9. Initiating devices
10. Guard's tour equipment
11. Combination systems (a) Fire extinguisher electronic monitoring device/systems
(b) Carbon monoxide detectors/systems
12. Interface equipment
13. Alarm notification appliances
14. Exit marking audible notification appliances
15. Supervising station alarm systems-transmitters
16. Special procedures
17. Supervising station alarm systems-receivers
18. Public emergency alarm reporting system transmission equipment
20. Mass notification system, non-supervised systems installed prior to adoption of this edition
Table 14.4.2.2. Test Methods
5. Batteries (General Tests)
(b) Battery Replacement - Batteries shall be replaced in accordance with the recommendations of the
alarm equipment manufacturer or when the recharged battery voltage or
current falls below the manufacturer ' s recommendations.
14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
Table 14.4.5 Testing Frequencies.
6. Batteries - fire alarm systems
(d) Sealed lead-acid type
(1) Charger test: Initial/Reacceptance and Annually
(2) Discharge test (30 minutes): Initial/Reacceptance and Annually
(3) Load voltage test: Initial/Reacceptance and Semiannually
14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.
14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(S) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with14.4.5.3.3.

Findings:

During document review and interview with Maintenance Staff on 6/17/25, the FAS was observed and records were requested and reviewed.

1. At 12:32 p.m., a review of the most recent smoke detector sensitivity testing report indicated the smoke detector sensitivity testing was last performed on 4/20/2021. Upon interview, the Maintenance Staff confirmed that the facility had not performed a smoke detector sensitivity test since 2021 and was unaware of the requirement.

2. At 12:42 p.m., the facility failed to provide upon request the semi-annual FAS inspection report. The most recent annual reports were dated 4/15/25 and 5/15/24, respectively. Upon interview, the Maintenance Staff stated that the semi-annual FAS inspection documentation was not available for review.

3. At 12:43 p.m., a review of the FAS inspection and test documentation showed that the facility failed to perform one of two required semi-annual load voltage tests on both sealed lead acid batteries in the fire alarm control panel. The most recent annual reports were dated 4/15/25 and 5/15/24, respectively, and no semi-annual inspection documentation was available. Upon interview, the Maintenance Staff stated that the semi-annual FAS inspection documentation was not available for review.

Based on record review and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by multiple deficiencies that were noted on the most recent five year inspection documentation, the failure to perform quarterly sprinkler inspections during the past year, and the failure to perform monthly visual inspections on the gauges and control valves. This affected one of one patients and one of one smoke compartments, and could result in an ineffective sprinkler coverage.

NFPA 101 Life Safety Code, 2012 edition
19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected
throughout by an approved, supervised automatic
sprinkler system in accordance with Section 9.7, unless otherwise
permitted by 19.3.5.5.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years thereafter 2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Findings:

During a tour of the facility and interview with the Maintenance Staff on 6/17/25, the automatic sprinkler system documentation was requested and reviewed.

1. At 12:27 p.m., a review of the five year sprinkler inspection documentation, dated 11/15/24, indicated the facility had no general information signage regarding the antifreeze loops, type, and quantity. Upon interview, the Maintenance Staff stated that the facility had not addressed the deficiencies noted on the five year inspection.

2. At 12:28 p.m., a review of the five year sprinkler inspection documentation, dated 11/15/24, indicated the most sprinklers at the facility were over 50 years old and required field service testing. Upon interview, the Maintenance Staff stated that the facility had not addressed the deficiencies noted on the five year inspection.

3. At 12:35 p.m., the facility failed to provide upon request three of four quarterly sprinkler inspection documentation. The most recent report was dated 11/15/24, which was also a five year report. Upon interview, the Maintenance Staff stated that the quarterly sprinkler inspections were not documented correctly.

4. At 12:40 p.m., the facility failed to provide upon request the monthly visual inspection documentation of the gauges and control valves. Upon interview, the Maintenance Staff confirmed that the facility did not document the monthly visual inspections of the gauges and control valves.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced a fire extinguisher that was missing the class K placard. This affected one of one residents could result in delayed use of the fire extinguishers in the event of a fire.

NFPA 101 Life Safety Code 2012 edition
19.3.5.12 Portable fire extinguishers shall be provided in all
health care occupancies in accordance with 9.7.4.1.
9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed,
inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers.
5.5.5* Class K Cooking Media Fires. Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires.
5.5.5.1 Class K fire extinguishers manufactured after January 1, 2002, shall not be equipped with extended wand-type discharge devices.
5.5.5.2 Fire extinguishers installed specifically for the protection of cooking appliances that use combustible cooking media (animal or vegetable oils and fats) without a Class K rating shall be removed from service.
5.5.5.3* A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher.

Findings:

During a tour of the facility and interview with the Maintenance Director on 6/17/25, the facility's fire extinguishers were observed.

At 10:17 a.m., the class K fire extinguisher in the kitchen area failed to have a Class K placard. Upon interview, the Maintenance Staff was unaware of the Class K placard requirement.

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Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by a corridor door that failed to latch when tested. This could result in the passage of smoke in the event of a fire, and affected one of one smoke compartment and one of one patients.

Findings:

During a tour of the facility and interview with the Maintenance Staff on 6/17/25, the corridor doors were observed.

At 10:21 a.m., the corridor door with a self-closing device to patient room four failed to latch when tested. The door was tested three times and failed to latch on all three occasions. Upon interview, the Maintenance Staff stated that the door needed to be adjusted.

Based on document and interview, the facility failed to maintain the Emergency Power Supply System (EPSS). This was evidenced by the absence of a four-hour load test documentation for the 150 Kilowatt (kW) spark ignited Propane EPSS. This affected one of one patients and one of one smoke compartments, and could result in a malfunction of the EPSS in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1.
9.1.3.1 Emergency Generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition.
Chapter 8 Routine Maintenance and Operational Testing
8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.
8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.
8.4.1.1 If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, providing the same record as required by 8.3.4.
8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.
8.4.9* Level 1 EPSS shall be tested at least once within every 36 months.
8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS.

Findings:

During document review and interview with Maintenance Staff on 6/17/25, the EPSS documentation was requested.

At 12:56 p.m., the facility failed to provide upon request the four hour load test that was required to be performed on the 150 kW spark ignited Propane EPSS during the past three years. Upon interview, the Maintenance Staff confirmed that the four hour load test had not been performed on the EPSS during the past three years.

Based on observation and interview, the facility failed to maintain the gas equipment. This was evidenced by empty and full oxygen cylinders that failed to be segregated. This affected one of one patients and one of one smoke compartments, and could result in a delay in access to the oxygen equipment.

Findings:

During a tour of the facility and interview with the Maintenance Staff on 6/17/25, the Oxygen Storage Room was observed.

At 10:11 a.m., the oxygen storage room located in the emergency room area was observed with three full oxygen e-cylinders and four empty oxygen e-cylinders that failed to be segregated from each other. Upon interview, the Maintenance Staff stated that he was unaware that the empty and full oxygen cylinders were required to be segregated.