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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 sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following.

The boiler room is considered as a hazardous area, the door was not equipped with a self-closing device, as required.

Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.

The Director of Facility Management acknowledged the hazardous area enclosures and door condition during a tour of the facility.

STANDARD not met as evidenced. Based on observation and staff interviews of the emergency lighting, the facility failed to maintain the battery-powered emergency lights accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power.

No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds or annually for not less than 1 ½ hours

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The Director of Facility Management acknowledge the required testing of the emergency lighting during the tour of the facility.

STANDARD not met as evidenced by. During the walk through of the facility, with the Director of Facility Management the facility failed to maintain the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain 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.

The fire alarm system has a trouble signal on the main panel that indicates failure of the Clean Agent system.

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.

The fire alarm deficiency was discussed with the Director of Facility Management during the survey and again during the exit conference with the CEO.

STANDARD not met as evidenced by. Based on observation and staff interview during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 19.3.7.3 This deficient practice could affect all residents in all smoke compartment by allowing the spread of fire and smoke to the adjoining compartments.

Unsealed penetrations in the ceiling of the boiler room not sealed to maintain the 30-minute fire resistance rating of the smoke barrier, as required.

Life Safety Code Section 19.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than ½ hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.6.1 requires, in part, that the space between piping penetrations.

The Director of Facility Management acknowledge the penetrations during a tour of the facility.

STANDARD not met as evidenced by. It was determined by record review and staff interview during the course of the survey, the facility failed to perform and document the exercising of all fire and smoke damper at least every four years, in accordance with NFPA 80, Standard for Fire Doors and other Opening Protectives. This deficient practice could affect all residents, staff and visitors if the smoke dampers malfunction due to improper maintenance should a fire occu
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Records were not available at the time of the survey to document the inspection and testing operation of the fire dampers install in the facility as required every 6 years.

NFPA 80-2010 Standard for Fire Doors and other Opening Protectives, Chapter 19 Section 19.4 1.1. The test inspection frequency shall then be every 4 years, except in hospitals, where frequency shall be every 6 years.

The smoke and fire dampers deficiency item was discussed with the Director of Facility Management during record review of required documentation.

STANDARD not met as evidenced by. It was determined by record review and staff interview during the course of the survey, the facility failed to perform and document the exercising of all fire and smoke damper at least every four years, in accordance with NFPA 80, Standard for Fire Doors and other Opening Protectives. This deficient practice could affect all residents, staff and visitors if the smoke dampers malfunction due to improper maintenance should a fire occur.

Records were not available at the time of the survey to document the inspection and testing operation of the fire dampers install in the facility as required every 6 years.

NFPA 80-2010 Standard for Fire Doors and other Opening Protectives, Chapter 19 Section 19.4 1.1. The test inspection frequency shall then be every 4 years, except in hospitals, where frequency shall be every 6 years.

The smoke and fire dampers deficiency item was discussed with the Director of Facility Management during record review of required documentation.

This STANDARD is not met as evidenced by: Through observation during the walkthrough of the survey it was determined that the facility failed to meet the Utilities- gas and electric requirements in accordance with NFPA 101 and NFPA 54. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one (1) smoke compartment.

Orifice for dryer not sized correctly currently set for 0-2000 feet according to dryer data plate.

NFPA 54, section 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft. (600 m) shall be reduced in accordance with one of the following methods:
(1) At the rate of 4 percent for each 1000 ft. (300 m) above sea level before selecting appropriately sized appliance
(2) As permitted by the authority having jurisdiction
(3) In accordance with the manufacturer's installation instructions

The deficient items were discussed with the Director of Facility Management during the exit conference.

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.

Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct a fire drill on the second shift in the first quarter.

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.

The Director of Facility Management acknowledge the conditions of fire drills deficiency during record review of the facility.

STANDARD 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 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss.

The facility failed to provide documentation at the time of the survey to reflect that the emergency generator was inspected weekly and exercised under load at least monthly had occurred in the past 12 months 2022-2023.

8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

NFPA 110, Section 8.3.7. A fuel quality test shall be performed at least annually using applicable ASTM standards or the manufacturer's recommendations.


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