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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 areas in accordance with Life Safety Section 19.3.2.5. This deficient practice could affect all residents and staff in the main smoke compartment including the kitchen should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following.

Doors used as an opining protective for hazardous area requiring 1-hour separation between the main corridor and kitchen were not equipped with a self-closing device.

The Director of Maintenance acknowledged the area enclosures and door condition during a tour of the facility.

19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

STANDARD is not met as evidenced by: During the review of the facility records, with staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system cleaning schedule as required by NFPA 96, (Chapter 8, Section 8-3). This deficient practice could affect all residents, and staff should a fire occur due to grease build-up in the exhaust system and fail to operate effectively due to non-code compliant cleaning and maintenance. This was evidence by the following;

1.No documentation was available to confirm that the facility had the kitchen-hood-exhaust-system cleaned, or
schedule as required by NFPA 96.
2.Rang Hood exhaust fan does not turn on upon activation of the fire alarm as required by NFPA 96
3.Gas fired cooking equipment with casters where not limited by a restraining device as required by NFPA 54-9.6.1.2.

The Maintenance Director acknowledge the deficiencies of the Kitchen Hood System.

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.

Through record review, during the survey, it was determined that the facility failed to quarterly inspect and test the automatic sprinkler system as required by NFPA 25 during each quarter.

The CEO and Maintenance Director acknowledge the lack of the quarterly testing 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: 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 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This deficient practice could affect all residents, staff and visitors if the smoke dampers malfunction due to improper maintenance should a fire occur. This was evidenced by the following:

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 four years.

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

NFPA 90A, Chapter 3, Section 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

STANDARD is not met as evidenced by: Based on record review and discussion with staff during the course of the survey, it was determined that the facility failed to contain all required elements of the fire safety plan in accordance with the Life Safety Code, Section 19.7.2 and 19.7.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. This was evidenced by the following:

During review of the Fire Safety Plan it failed to contain the elements (3) "Emergency phone call to fire department".

The Director of Maintenance acknowledge the missing required element of the fire plan during the facility record review.

The Life Safety Code Section 19.7.2.3 requires that; a written health care occupancy fire safety plan shall provide for the following:
(1) Use of Alarms
(2) Transmission of alarm to the fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and buildings for evacuation
(9) Extinguishment of fire

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, the facility failed to conduct a fire drill on the second shift first and third quarter.

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 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 battery conductance testing in connection with the emergency power supply system (emergency generator) monthly.

The emergency power supply system deficiency item was discussed with the Director of Maintenance during the survey.

NFPA 110, Section 8.3.7. 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.