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Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101

Sprinkler report listed defienicies to be corrected
- No coverage hallway in basement
- Flow switches not latching
- Hornstrobe did not activate

NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12

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

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6

Fire drills closer than hour apart not at varied times

NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

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

Based on observation and staff interview during the course of the survey it was determined the med gas systems was not maintained IAW NFPA 99.

Need Clean report for Medical Air Inspection Report - Med gas report showed deficiencies

5.1.14.2.1* General.

Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

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

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following:

Generator battery Conductance not being recorded on reports

NFPA 110
8.1.1 The routine Maintenance and operational testing program shall be based on all of the following:

Manufacturers recommendations
Instruction manuals
Minimum requirements of this chapter
The authority having jurisdiction

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