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Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:

1) 2-hour rated wall not finished on east corridor

NFPA 101
19.1.3.3* Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to provide services simultaneously
for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
(3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.


This deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

1) The deadbolts on the front and rear egress doors lack proper signage, and the doors also need to be key-operated in accordance with NFPA 101 7.2.1.5.5.

NFPA 101
39.2.2.2.2* Locks complying with 7.2.1.5.5 shall be permitted only on principal entrance/exit doors.

NFPA 101
7.2.1.5.5 Key-Operated Locks.
7.2.1.5.5.1 Exterior door assemblies shall be permitted to have key-operated locks from the egress side, provided that all of the following criteria are met:
(1) This alternative is permitted in Chapters 11 through 43 for the specific occupancy.
(2) A readily visible, durable sign in letters not less than 1 in. (25 mm) high on a contrasting background that reads as follows is located on or adjacent to the door leaf: THIS
DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED.
(3) The locking device is of a type that is readily distinguishable as locked.
(4) A key is immediately available to any occupant inside the building when it is locked.

NFPA 101, 7.2.1.5.10 A latch or other fastening device on a door leaf shall be provided with a releasing device that has an obvious method of operation, and that is readily operated under all lighting conditions.


NFPA 101, 7.2.1.5.10.2

The releasing mechanism shall open the door leaf with not more than one releasing operation unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6.

This deficiency could affect occupants, including residents, staff, and visitors throughout the facility. Deficient item(s) were discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:

1) More exit signage is needed for the rear egress access.

NFPA 101
39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

NFPA 101
7.10.1.5.1 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:

1) 1-hour rated smoke barrier PCU hall above smoke doors needs to be topped out
2) 1-hour wall on soiled linen needs top out
3) 1-hour firewall in the mechanical room needs to be topped out
4) 1-hour fire wall west side central supply needs to be repaired

NFPA 101
18.3.2.1* Hazardous Areas.
Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated.

NFPA 101
4.5.8 Maintenance.
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:

1) Fire alarm Semi-Annual: Not Provided
2) Fire alarm Sensitivity test (2 Years) (72 14.4.5.3.2): Not Provided

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.

NFPA 101, Section 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 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72.

NFPA 72 Table14.4.5 Testing Frequencies

This deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:

1) Fire alarm annual notes 5 deficiencies that need to be corrected
a) horn and strobes not syncing
b) 4 Heat detectors are not operational
2) Fire Alarm Sensitivity test (2 Years) (72 14.4.5.3.2): 7.31.21 Alpine security, overdue

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.

NFPA 101, Section 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 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72.

NFPA 72 14.2.1.2.2 System defects and malfunctions shall be corrected.

NFPA 72 Table14.4.5 Testing Frequencies

This deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:

1) Fire sprinkler Weekly/Monthly: Not Provided
2) Fire sprinkler Quarterly: Not Provided
3) Fire sprinkler Semi-Annual: Not Provided

Based on a record review, it was determined that the facility failed to maintain the fire sprinkler system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.

NFPA 101, 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, Chapter 5 Sprinkler Systems
Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25, Chapter 13 Common Components and Valves
Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

This deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 25. This was evidenced by:

1) Fire sprinkler semi-annual report indicates that they are not actuating the supervisory signals
2) Fire sprinkler annual report indicates that they are not exercising the control valves.
3) Fire sprinkler 3 Year Full Trip: 6.10.22 Cooper Fire, Not adequate information on the report
4) missing trim plate in the decontamination room

Based on a record review, it was determined that the facility failed to maintain the fire sprinkler system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.

NFPA 101, 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, Chapter 5 Sprinkler Systems
Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25, Chapter 13 Common Components and Valves
Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.

This deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99. This was evidenced by:

1) Defend in Place strategy is being utilized for patient care, fire sprinkler and fire alarm systems do not meet NFPA 99 requirements for Defend in Place.

NFPA 99
15.7.4.3 Defend in Place. For new and existing facilities, where the response to a fire is to defend in place within a safe place in the building, occupant notification shall be in accordance with the facility fire plan.

15.7.4.3.1* Where buildings are required to be subdivided into smoke compartments, fire alarm notification zones shall coincide with one or more smoke compartment boundaries or shall be in accordance with the facility fire plan.

15.8.1.2* Defend in Place. For new and existing facilities, where the response to a fire is to defend in place within a safe place in the building and not to automatically evacuate the building, sprinkler system zones shall coincide with smoke compartment boundaries or shall be in accordance with the facility fire plan.

This deficiency could affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the facility maintenance director during the exit conference.