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STANDARD is not met as evidenced by: Based observation and discussion during the tour of the facility, it was determined the facility failed to install and 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 occupants, 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.

No documentation of the kitchens fire roll down door been inspected annually.

The Director of Maintenance acknowledged the condition of doors and assemblies during the tour of the facility.
8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

STANDARD is not met as evidenced by: Through record review and staff interview during the survey, the facility failed to inspect and test the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor within the facility if the fire alarm system failed to operate if a fire was to occur. This was evidenced by the following:

At the time of the survey, no documentation was available to indicate the Simi-Annual Testing of the fire alarm system had occurred in the past year

At the time of the survey, no documentation was available to indicate the sensitivity test has been performed in the last 2 years.

The Director of Maintenance acknowledge the lack of testing of the fire alarm system in the past year during the tour of the facility.

2012 Life Safety Code 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 72 2010: 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.
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.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to install sprinkler protection coverage to all areas in accordance per NFPA 101 Section 19.3.5.1, 9.7.1.1; NFPA 13 Section 8.17.4.2. Failure to protect the facility with an automatic sprinkler system as required increases the risk of death or injury due to fire of all occupants in the facility. This was evidenced by the following:

Imaging room in radiology has a shadow area, where there is no sprinkler coverage.

Sprinkler head in the freezer is dated 2009 and due for 10-year replacement

The Director of Maintenance acknowledge the lack of sprinkler coverage under the canopy during the tour of the facility.

NFPA 101 2012 Edition, Section 19.3.5.1 Buildings containing Hospitals 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.

STANDARD is not met as evidenced by: 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.

No documentation of the five-year internal pipe inspection.
No documentation of the gauges being inspected monthly.

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

NFPA 101Life 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

STANDARD is not met as evidenced by: 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 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 on each shift quarterly, 2nd shifts missing 2 drills for 3rd quarter in 2022.

The Director of Maintenance 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

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the central supply system identification and labeling accordance with National Fire Protection Association 99, Health care code. This deficient practice could affect all residents in the smoke compartments due to increased potential hazard. This was evidence by the following:

Storage next to Rehabilitation Services had no sign of oxygen being stored.

The Director of Maintenance acknowledge the lack of signage on storage closet for the oxygen.

Containers, cylinders and tanks are designed, fabricated, tested, and marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations containing only oxygen or medical air have doors labeled with "Medical Gases, NO Smoking, or Open Flame". Locations containing other gases have doors labeled "Positive Pressure Gases, NO Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Opening." 5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99)

STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.7.1 Maintenance and Operational Testing. This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss.
This was evidenced by the following

At the time of the survey no records were available to verify testing and recording of the annual fuel quality testing.

The emergency power supply system deficiency item was discussed with the Director of Maintenance during the survey and again during the exit conference with the Administrator.

NFPA 110, Section 8.3.8. A fuel quality test shall be performed at least annually using tests approved by ASTM standards