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Based on record review, the facility failed to provide a properly maintained fire alarm system as required by NFPA 72 Table 14.4.3.2. (27). This deficiency practice had potential of affecting the entire facility on the day of facility survey.

Findings include:

On June 29, 2021, at 3:30 PM, observation and record review revealed the facility was unable to provide the current year (2021) documentation of annual and sensitivity inspection of the fire alarm system. Record review also revealed the last annual and sensitivity inspection of the fire alarm system was conducted on November 18, 2020.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/29/21.

Based on observation and document review, the facility failed to provide the maintenance and testing records of sprinkler system in accordance with NFPA 25 section 5.2.4. This standard deficiency affected entire facility on day of survey.

On June 29, 2021, at 3:45 PM, observation and record review revealed the facility was unable to provide the records of the quarterly waterflow test for the sprinkler system.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/29/21.

Based on observation, the facility failed to provide the fire extinguisher in accordance with NFPA 101 section 19.3.5.12, NFPA 10. This standard deficiency affected entire facility on day of survey.

Findings Include:

On June 29, 2021, at 10:45 AM, observation reveal fire extinguishers were improperly installed at height of 6 feet in the following areas of the facility:

1. Laboratory
2. Physical Therapy Room
3. The Chapel
These fire extinguishers shall be installed no more than five (5) feet above the floor.
The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/29/21.

Based on observation the facility failed to provide the required automatic smoke detection system in accordance with NFPA 101 section 19.3.6.1 This standard deficiency affected entire facility on day of survey.

Findings Include:

On June 29, 2021, at 10:45 AM, observation revealed no hard-wired smoke detector in Vending Machine Area of the facility. This area was open to the main corridor of the facility and was incapable of resisting the passage of smoke throughout the facility.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/29/21.

Based on the observation, the facility failed to provide the corridor door in accordance with NFPA 101 section 19.3.6.3.6. This standard deficiency affected entire facility on day of survey.

Findings Include:

On June 29, 2021, at 10:45 AM, observation revealed the Pharmacy Dutch door did not close to a positive latching position and was incapable of resisting the passage of smoke throughout the facility.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/29/21.

Based on observations the facility failed to provide the required ½ hour fire resistance rating for smoke barrier walls in accordance with NFPA 101 sections 19.3.7.3, 8.5, 8.5.6. This standard deficiency affected entire facility on day of survey.

Findings Include:

On June 29, 2021, at 11:00 AM, observation revealed open, unsealed penetrations around blue 'data cables' at Senior Care smoke barrier wall of the facility. This smoke barrier terminated at a solid 1-hour fire rated ceiling that was not intact and was incapable of resisting the passage of smoke throughout the facility.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/29/21.

Based on the observation and testing, the facility failed to provide the generator in accordance with NFPA 110 section 4.1. This standard deficiency affected entire facility on the day of the survey.

Findings include:

On 6/29/21 at 3:20 PM, observation and testing revealed the generator was incapable of cranking and transferring power to the facility within 10 seconds.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/29/21.