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Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. NFPA 13:5.1.1.2 states, " Table 5.1.1.2 shall be used to determine the minimum
required frequencies for inspection, testing, and maintenance."

Findings:

During the facility tour and record review, on 5/25/2021 between the hours of 9:30am to 4:30pm it was noted that no documentation was provided for the 5 year internal inspection. It was also noted that besides the annual requirements for inspection, testing, and maintenance no other inspection, testing, or maintenance referenced by NFPA 12 Table 5.1.1.2 was performed and/or documented. It was also observed throughout the facility that numerous recessed sprinkler heads had the caps missing.

Interview with the facility manager revealed the facility was not aware that the annual and quarterly inspections had not been conducted on the automatic sprinkler system.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. 2 of 6 smoke barriers were deficient.

Findings:

During the facility tour, on 5/25/2021 between the hours of 9:30am to 4:30pm it was observed that a large gap was present in the one hour rated smoke barrier above the double doors leading towards out patient surgery and radiology. It was also observed that the front stair enclosure had penetrations on both sides of the 1 hour fire rated assembly on the first floor.

Interview with the Facility Manager revealed the facility was not aware of unsealed penetration and gaps.

Based on record review the facility failed to assure that the elevators, for emergency personnel, are inspected and tested as required by ASME A17.1. The response time for responding rescue personnel could be delayed when the elevator equipment does not have the required programming.

Findings:

During record review, on 5/25/2021 between the hours of 9:30am to 4:30pm it was noted that no documentation was provided for the inspection and testing of the elevator and the monthly operation of the firefighter's service.

Interview with the Facility Manager revealed the facility was not aware that the elevator was not being inspected properly and/or documented.

Based on visual observation the facility failed to assure that installed fire doors were inspected and maintained. The fire doors restrict the movement of fire from one compartment to another. NFPA 80:5.2.3.5.2 states, "As a minimum, the following items shall be verified: (1) Labels are clearly visible and legible. (2) No open holes or breaks exist in surfaces of either the door or frame. (3) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (4) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (5) No parts are missing or broken. (6) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (7) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (8) If a coordinator is installed, the inactive leaf closes before the active leaf. (9) Latching hardware operates and secures the door when it is in the closed position. (10) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (11) No field modifications to the door assembly have been performed that void the label. (12) Meeting edge protection, gasketing and edge seals, where required, are inspected to verify their presence and integrity. (13) Signage affixed to a door meets the requirements listed in 4.1.4." The deficient practice had the potential to affect of residents.

Findings:

During the facility tour, on 5/25/2021 between the hours of 9:30am to 4:30pm it was observed that multiple fire rated doors throughout the facility had missing screws, door closures missing or not fully closing the door, and door/frame tags painted. It was also noted that no documentation was provided for the annual fire door inspection.

Interview with the Facility Manager revealed the facility was not aware that the fire doors had not been properly inspected and maintained.

Based on visual observation and record review the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. NFPA 110:7.13.3 states, "The authority having jurisdiction (AHJ) shall be given advance notification of the time at which the acceptance test is to be performed so that the authority can witness the test." In cases of a power outage the emergency generator powers essential life safety equipment for the facility. 7 of 12 months were deficient.

Findings:

During the facility tour and record review, on 5/25/2021 between the hours of 9:30am to 4:30pm the following was noted:

1) It was noted that the weekly testings were not performed and/or documented for one week in six of the months and two weeks for one month.
2) The AHJ did not receive a submittal for the new generator and the generator has not been provided with an acceptance test and/or the AHJ was not notified of the acceptance test.


Interview with the Facility Manager revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator.