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Based on record review and interview made in the presence of the administrator on 05-21-2019 it was determined that the facility failed to develop and maintain a comprehensive emergency preparedness program that must be reviewed, and updated at least annually.

This deficiency affected 1 of 1 required emergency preparedness program.

Findings include:
During the record review and interview the facility failed to provide documentation of a comprehensive emergency preparedness program in accordance with 42 Code of Federal Regulations, 482.15

Based upon observations made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not continuously maintain the means of egress and exits to the public way at all times in accordance with NFPA 101: 19.2.1, 7.1.10.1

This deficiency affected 3 of 3 smoke compartments.

Findings include:
1-During the record review it was discovered that the facility did not test and maintain the annual inspections of fire doors in accordance with NFPA 80, NFPA 25

Based upon observations made in the presence of the plant manager on 05-21-2019 it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 19.2.9.1.

This deficiency affected all emergency lights.

Findings include:
During the record review it was observed that the facility failed to provide the documentation of the monthly testing of the emergency lights with battery backup in accordance with NFPA 101 7.9.3.

Based on observations in the presence of the plant manager cooking equipment is not protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

This deficiency affected 1 of 2 of several required tests.


Findings include:
During the record review the facilities records indicated that there was 9 months between inspections of the hood extinguishing system. Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be inspected by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months in accordance with NFPA 96 11.2.1
Ref: 2012 NFPA 101 19.3.2.5.1, 9.2.3 and NFPA 96 12.1.2.4

Based upon record review made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not maintain the fire alarm system, Device test results (alarm initiating, supervisory alarm initiating, and notification) are required to be itemized list with the following information, device type, address, location, and test result as required. In accordance with Ref: 2012 NFPA 101 Section 19.3.4.1, 9.6.1.5; 2010 NFPA 72 Table 14.4.5 Item 20; Ref: 2012 NFPA 101 Section 19.3.4.1, 9.6.1.5; 2010 NFPA 72 Section 14.6.2.4, Figure 14.6.2.4 Section 7.12-7.14 and page 11 of 11)

This deficiency affected 3 of several required tests.

Findings include:
1- During the record review the facility failed to provide documentation that the fire alarm control panel batteries had been tested under load two times in the last year. Batteries need to be tested semiannually in accordance with NFPA 101 20.3.4.1. & 9.6.1.1.; and NFPA 72 Table 14.4.5
2- During the record review portion of the survey the facility failed to produce documentation of two riser tamper switch tests only one test was documented. Valve supervisory alarm devices shall be tested semiannually in accordance with NFPA 101 20.3.5.1, 9.7.5. And NFPA 72 table 14.4.5. (15.l-1)
3- During the record review documentation of device test results failed to provide an itemized list with the following information, device type, address, location, and test result as required in accordance with NFPA 101 Section 19.3.4.1, 9.6.1.5 and NFPA 72 14.6.2.4.

Based upon observations/record review made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101, 9.7.5.

This deficiency affected 1 of 1 required test.

Findings include:
1-During the record review it was determined that the facility failed to provide documentation that the fire risers water flow alarm test was conducted 2 times in the last year in accordance with NFPA 101 20.3.5.1; 9.7; 9.7.5; NFPA 72 Table 7-3.1. (2012 table 14.3.1)
2- During the facility tour the fire sprinkler head located in the radiology ultra sound restroom had paint and or corrosion on the body of the sprinkler head that could affect the proper function of the sprinkler in accordance with NFPA 101 19.3.5.1; 9.7.5 and NFPA 25
3- During the facility tour the fire sprinkler head located in the I.T. closet in the emergency room had paint and or corrosion on the body of the sprinkler head that could affect the proper function of the sprinkler in accordance with NFPA 101 19.3.5.1; 9.7.5 and NFPA 25
4- During the facility tour the fire sprinkler head located in resident room 123 "O.B." had paint and or corrosion on the body of the sprinkler head that could affect the proper function of the sprinkler in accordance with NFPA 101 19.3.5.1; 9.7.5 and NFPA 25
5- During the facility tour the fire sprinkler head located in the SNF nurses station had paint and or corrosion on the body of the sprinkler head that could affect the proper function of the sprinkler in accordance with NFPA 101 19.3.5.1; 9.7.5 and NFPA 25
6- During the facility tour the fire sprinkler head located in the SNF south hall had paint and or corrosion on the body of the sprinkler head that could affect the proper function of the sprinkler in accordance with NFPA 101 19.3.5.1; 9.7.5 and NFPA 25
7- During the facility tour the fire sprinkler head located in resident room 207 had paint and or corrosion on the body of the sprinkler head that could affect the proper function of the sprinkler in accordance with NFPA 101 19.3.5.1; 9.7.5 and NFPA 25
8- During the facility tour the fire sprinkler head located in the SNF nutrition/ice room had the ice machine blocking the sprinkler head that could affect the proper function of the sprinkler in accordance with NFPA 101 19.3.5.1; 9.7.5 and NFPA 25

Based upon observations made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not maintain portable fire extinguishers in accordance with NFPA 10 and NFPA 101 19.3.5.12.

This deficiency affected 2 of many fire extinguishers.

Findings include:

During the record review the facility failed to provide a documentation indicating that the kitchen K extinguisher "expired 2016" and the I.T. Storage room extinguisher "expired 2015" were serviced/inspected. In addition to the required tag or label, a permanent file record should be kept for each fire extinguisher. This file record should include the following information, as applicable:
(1) Maintenance date and the name of the person and the agency performing the maintenance
(2) Date of the last recharge and the name of the person and the agency performing the recharge
(3) Hydrostatic retest date and the name of the person and the agency performing the hydrostatic test
(4) Description of dents remaining after passing of the hydrostatic test
(5) Date of the 6-year maintenance for stored-pressure dry chemical and halogenated agent types.
In accordance with NFPA 101 19.3.5.12 and NFPA 10 7.3.3, 7.2.2

Based upon observations made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not maintain the smoke barriers to provide at least a one-half hour fire resistance rating in accordance with NFPA 101 19.3.7.

The deficiency affected 3 of 3 smoke compartments

Findings include:
1-During the tour of the facility it was observed that the fire/smoke barrier wall above the ceiling in the main hallway corridor had 2 4" holes. Any required fire/smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating in accordance with NFPA 101 19.3.7.3.
2- During the tour of the facility it was observed that the fire/smoke barrier wall above the ceiling in the I.T. room had a approximate penetration 3"x6" and a 2" in the rated wall. Any required smoke/fire barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating in accordance with NFPA 101 19.3.7.3.

Based upon observations made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 1 of several GFICs and 1 of several electrical rooms.

Findings include
1-During the facility tour it was observed that the emergency outlets in the laboratory were not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2- During the facility tour it was observed that the door to the facility "shared" electrical room in the waiting area had the door to the room blocked open to allow cooling into the room allowing unauthorized access to unqualified persons not in accordance with NFPA 70,110-31

Based upon made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not install or maintain the buildings heating, ventilating and air conditioning systems in accordance with NFPA 101 19.5.2.1 and 9.2., NFPA 72 Table 14.4.2.2

This deficiency affected all fire/smoke dampers.

Findings include:
1-During the record review the facility failed to provide the testing documentation that the (Emergency control functions) smoke damper operations had been tested annually with the initiating device that activates the damper. All inspections and testing shall be documented, indicating the location of the fire, fire smoke dampers, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected in accordance with NFPA 80 19.3.4., NFPA 72 Table 14.4.2.2 and not in accordance with NFPA 19.5.2.1, 9.2 and NFPA 72 Table 14.4.2.2

Based upon record review made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.4. Through 19.7.1.7. (ASC 21.7.1.4 through 21.7.1.7)

This deficiency affected 6 of the required 12 fire drills.

Findings include:
During the record review the facility failed to provide documentation that 6 of the required 12 fire drills were conducted on the second shift. The plant manager confirmed these findings. Fire drills shall be held at unexpected time under varying conditions at least quarterly on each shift " the facility runs two shifts from 7:00 am to 7:00 pm and 7:00 pm to 7:00 am" in accordance with NFPA 101 19.7.1.4. Through 19.7.1.7.

Based upon observations made during the record review in the presence of the plant manager on 05-21-2019 it was determined that the facility did not perform a maintenance program on the medical gases in accordance with NFPA 101 19.3.2.4, NFPA 99 5.1.14.2.3,5.1.14.2.2,5.1.15,5.2.145.3.13.4.2,

The deficiency affected all required medical gas maintenance.

Findings Include.
During the record review it was discovered that the facility did not have the required documentation to show that there was any of the required maintenance being completed on the medical gas system in accordance with NFPA 99 5.1.14.2.3, 5.1, 14.2.2, 5.1.15, 5.2.145.3.13.4.2.

Based upon observations made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not test the Line Isolation Monitors in accordance with NFPA 99 6.3.4.1.4, 6.3.3.3.2

The deficiency affected the line isolation monitor.

Findings include:
1-During the document review it discovered that there was no tests being performed on the Line Isolation Monitor circuits. .Line Isolation Monitors shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).
For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. And not in accordance with NFPA 99 6.3.4.1.4

Based upon record review made in the presence of the plant manager on 05-21-2019, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 99 6.4.4 and NFPA 110 8.4.2.3.

This deficiency affected one of the required tests.

Findings include:
1-During the record review the facility failed to provide documentation that the Maintenance of the generator batteries had been conducted. Maintenance of Lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted in accordance with NFPA 110 8.3, 8.3.7

Based upon observations made in the presence of the the plant manager on
05-21-2019, it was determined that the facility did not use power and extension cords in accordance with NFPA 101 19.5.1 and 9.1.2

This deficiency affected 1 of many areas.

Findings include:

During the facility tour a power strip were observed to be "daisy chained" at the nurses station. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 70 110-3b,