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Based on observation and staff interview during the survey, it was determined that the facility failed to maintain did not maintain the exit discharge in accordance with NFPA 101.

Egress from MRI has change in elevation more 1/4in on ramp exiting from MRI area
Egress from MRI is not protected from weather/element in case of need to evacuate in inclement weather

NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code Sections 19.7.9.3.1.1.

Emergency Lighting 30sec/90min - No reports available at time of inspection
Emergency Exit Lighting 30sec/90min - No reports available at time of inspection

NFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. (3) 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.

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, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19.
This deficient practice could affect all residents, staff and visitors throughout the facility if an exit cannot be identified during an emergency.

Exit sign not viewable by room 212

NFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner.

NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with theMaintenance director at the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2.

Kitchen stove and cooking equipment missing wheel blocking and/or a means to ensure the appliance is returned to its design location.
Hood cleaning - No report available at time of inspection


NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations.

NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions.

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 facility failed to maintain Alcohol Based Hand Rub Dispensers in accordance with NFPA 101.

1 dispensers found installed within one inch of an electrical source by exam room 2

NFPA 101 21.3.2.6
8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source

(b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source

(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source
These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

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

No quarterly sprinkler inspections available at time of inspection

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 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

Nurses station concealed head need to be repaired IAW UL listing
Only annual sprinkler inspection report legible

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 observation and staff interview during the survey, it was determined that the facility failed to maintain corridor doors in accordance with Life Safety Code Section and NFPA 80. This was evidenced by the following:

Fire and Smoke door inspection report not available at the time of inspection

NFPA 80 5.2.1*

Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

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 facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1.
This was evidenced by the following:

Electrical Room penetrations need to be protected
Med Vac room penetrations need to be protected
Fire riser room penetrations need to be protected
2 hour fire wall has multiple penetrations throughout facility

NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

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 facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1.
This was evidenced by the following:

IT room penetrations need to repair with approved listed repair to maintain fire resistive protection
Penetration grey wire in mech room 800
Fire shutter inspection tag from 2019


NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

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 Administrator and Maintenance director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility did not develop Smoking regulations IAW NFPA (12) 19.7.4

Smoking Policy: Non Compliant (Need to address non-smoking around oxygen)

19.7.4* Smoking.

Smoking regulations shall be adopted and shall include not less than the following provisions:

(1)Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

(2)In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

(3) Smoking by patients classified as not responsible shall be prohibited.

(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.

(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.

(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

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 did not develop Smoking regulations IAW NFPA 101 (12) 19.7.4

Smoking Policy: Non Compliant (Need to address non-smoking around oxygen)

19.7.4* Smoking.

Smoking regulations shall be adopted and shall include not less than the following provisions:

(1)Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

(2)In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

(3) Smoking by patients classified as not responsible shall be prohibited.

(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.

(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.

(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

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.

Through documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:

No Receptacle Polarity/Retention inspection available at the time of inspection

NFPA Standard: NFPA 99 Health Care Facilities Code (2012)

6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

These deficiencies have 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:

Gen shut off needs to be wired
Generators Items for inspection not identified IAW NFPA 110 (2010) Fig A.8.3.1 (a)

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.

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:

No generator conductance testing
No transfer time for generator listed on reports
Generators Items for inspection not listed IAW NFPA 110 (2010) Fig A.8.3.1 (a)
Emergency stop needs to be installed outside of closure

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.