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This Standard is not met as evidenced by:
Based on a review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 42 CFR 482.15 (a)(1) & (2).
Section 42 CFR 482.15 (a)(1) & (2) requires the facility develop and maintain an emergency preparedness plan that must be reviewed and updated at least bi-annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Findings Include:
A review of the facility's Emergency Preparedness (EP) conducted on 04/08/25 indicates the facility did not produce a facility-based and community-based risk assessment at the time of survey.

As a result of failing to provide an aligned EP program that utilized a facility-based and community-based risk assessment, the facility failed to ensure compliance with the requirements of CFR Section 42 CFR 482.15 (a)(1) & (2).

This deficient practice could affect all patients, visitors and staff in the event of an actual emergency where the EP must be utilized.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.

This Standard is not met as evidenced by:
Based on a review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of 42 CFR Section 42 CFR 482.15 (d) (1) & (2).
42 CFR 482.15 (d) requires the facility to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The Hospital must do the following:
1) Participate in an annual full-scale exercise that is community-based; or
a. When a community-based exercise is not accessible, conduct an annual individual, facility ¿based functional exercise.
b. If the Hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Hospital is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
2) Conduct an additional annual exercise that may include, but is not limited to the following:
a. A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
b. A mock disaster drill; or
c. A tabletop exercise or workshop that is led by a facilitator includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

Findings Include:
A review of the facility's Emergency Preparedness (EP) conducted on 04/08/25 indicates the facility did not produce documentation of the requirements of (1) or (2). Therefore, the facility is not in compliance with the requirements of 42 CFR 482.15 (d) (1) & (2).

This deficient practice could affect all patients, visitors and staff in the event of an actual emergency where the EP must be utilized.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.

Based on observations, the facility failed to ensure that hazardous areas were enclosed as required.

Section 19.3.2.1.5 states that hazardous areas shall include, but shall not be restricted to the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered
a severe hazard

Hazardous areas are:
1. Protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or
2. An automatic fire extinguishing system in accordance with 8.7.1.
When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4.

Section 8.4.3.4 states that door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Section 8.4.3.5 states that doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.

NFPA 80, section 6.1.4.2.1, states that self-closing doors shall swing easily and freely and
shall be equipped with a closing device to cause the door to close and latch each time it is opened.

NFPA 80, section 7.1.4 Operation of Doors.
Section 7.1.4.1 states that the doors shall swing easily and freely on their hinges.
Section 7.1.4.2 states that the latches shall operate freely.

NFPA 80, section 4.8.4 Clearance.
Section 4.8.4.1 states the clearance under the bottom of a door shall be a maximum of 3.4 in. (19 mm).

Findings Include:

On 04/07/25, while touring the facility, it was noted that;

1. The basement level ceiling has several unsealed holes, located throughout the basement where access was cut in the gypsum wallboard (GWB) ceiling and left open, nullifying the smoke resisting partitions and doors in accordance with 8.4.

2. The Soiled Utility Closet, adjacent to room # 106 not equipped with function door closing device

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.
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This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that all required areas are protected by the automatic sprinkler system.
NFPPA 101 section 19.3.5.1 states buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
NFPA 101 section 19.3.5.3 states where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
NFPA 101 section 19.3.5.4 states the sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1).
NFPA 101 section 19.3.5.5 states in Type I and Type II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as non-sprinklered.
NFPA 101 section 9.7.1.1 states each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height
NFPA 101 section 9.7.5 states that all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings Include:
During the morning and afternoon hours of 04/07/25 while touring the facility, and based upon documentation from Johnson Controls dated 03/21/24, 06/06/24, and 09/06/24 and upon documentation provided by the facility, it was identified that the following was missing from the documentation for the sprinkler system:
1) The facility failed to produce any documentation of monthly psi checks of the sprinkler system.
2) No sprinkler maintenance records were produced at time of survey for Q1 2025 or Q4 2024.
3) Gauges in the sprinkler room were dated January 2020, so should have been replaced.
This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation if a fire were to occur and activation of the sprinkler system were necessary.

As a result, the facility failed to maintain its sprinkler system in accordance with NFPA 13, NFPA 25 and NFPA 101 section 19.3.5.1.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19, Section 19.3.6.1 of the 2012 edition of NFPA 101 "Life Safety Code" and Chapter 17 Section 17.7.3.2.3.1 of the 2012 edition of NFPA 72 "National Fire Alarm and Signaling Code".

NFPA 101 Chapter 19, Section 19.3.6.1 "Corridor Separation" sub-section (7) states spaces, other than patient sleeping rooms, treatment rooms, and hazardous areas, shall be permitted to be open to the corridor and unlimited in area, provided that all of the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic
smoke detection system in accordance with 19.3.4.
(b)Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed
fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

NFPA 72 Section 17.7.3.2.3.1 states that In the absence of specific performance-based design criteria, smooth ceiling smoke detector spacing shall be a nominal 30 ft (9.1 m).

Findings Include:

On 04/07/25, observations revealed that the open sitting area, adjacent to the South Wing's nurses station, to be open to corridor and not equipped with electrically supervised automatic smoke detectors.

As a result of the finding the facility is found to be non-compliant with criteria (1)(a) of NFPA 101 Chapter 19 Section 19.3.6.1 and Chapter 17 Section 17.7.3.2.3.1. of NFPA 72.

Note: These particular spaces are not arranged and located so as to allow the whole room direct supervision by the facility staff from a nurses' station or similar space.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.

This Standard is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain smoke barriers in accordance with NFPA 101 Section 19.3.7.3, and section 8.5.

NFPA 101 section 19.3.7.3 states any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

NFPA 101 section 8.5.1 states where required by Chapters 11 through 43, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

NFPA 101 section 8.5.2.1 states smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof.

NFPA 101 section 8.5.2.2 states smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

NFPA 101 section 8.5.2.1 states 8.5.6.1 the provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers.

NFPA 101 section 8.5.6.2 states penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

Findings Include:

On 04/07/25 while touring the facility, the following items were observed regarding smoke barriers:

The Smoke Barrier wall separating the North Wing and the South Wing contained holes and unsealed voids around pipe, HVAC. duct, and electrical / communication wire penetrations above the in-lay ceiling tiles.

These penetrations were noted above the in-lay tiles at the cross-corridor doors and adjacent domestic laundry rooms

The Smoke Barrier wall separating the North Wing and the West Wing contained holes and unsealed voids around pipe and electrical / communication wire penetrations above the in-lay ceiling tiles at the cross-corridor doors.

Due to the penetrations/openings listed above, the facility failed to ensure its smoke barriers are maintained as required.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.

This Standard is not met as evidenced by:

Based on record review and later observed during the building tour, the facility failed to ensure that smoke barrier doors are maintained as required.

Section 19.3.7.8 states doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.

Section 8.5.4.1 states doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles.

Findings Include:

On 04/07/25 during facility tour, the smoke barrier door at the South Wing staff break room was not equipped with a door closing device.

As a result, the facility failed to comply with section 19.3.7.8 and 8.5.4 requiring smoke barrier doors to self close and be smoke tight.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.

This Standard is not met as evidenced by:
Based on observations and confirmed by staff, the facility failed to ensure compliancy with Chapter 19 of the 2012 edition of NFPA 101 "Life Safety Code." Chapter 19 "Existing Health Care Occupancies," section 19.7.1 Evacuation and Relocation Plan and Fire Drills states the requirements for fire drills.

NFPA 101 section 19.7.1.1 states the administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.
NFPA 101 section 19.7.1.2 states all employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.
NFPA 101 section 19.7.1.3 states a copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center.
NFPA 101 section 19.7.1.4* states fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.
NFPA 101 section 19.7.1.5 states infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
NFPA 101 section 19.7.1.6 states 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.
NFPA 101 section 19.7.1.7 states when drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
NFPA 101 section 19.7.1.8 states employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings Include:
During the morning and afternoon hours of 04/07/25 and based upon the facility's documentation, the following was observed concerning fire drills:
1) No fire drill conducted on 1st shift for Q1 2025. Staff indicated the drill was done in December 2024 to cover it, but code does not allow for that.
2) No alarm activation for fire drill conducted on 12/26/24 at 4:05pm on 2nd shift. Some of the records indicate it was sounded, others it was not. Cannot tell from documentation provided whether alarm was sounded or not.
3) Not enough variation in drill times.
a. 1st shift: 10:51, 10:40, 9:13
b. 2nd shift: 3:50, 4:02, 4:05, 3:25
c. 3rd shift: 3:30, 1:45, 2:15, 3:20

This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency where the fire safety plans are required to be utilized.

As a result, the facility failed to comply with NFPA 101 section 19.7.1 and document fire drills as required.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.

This standard is not met as evidenced by:

Based on observations and confirmed by the facility's Director of Maintenance during the building tour, the facility failed to ensure that portable space heaters are used in accordance with Section 19.7.8. of the 2012 edition of NFPA 101 Life Safety Code

-NFPA 101 section 19.7.8 states portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:

(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees F(100 degrees C).

Findings Include:

On 04/07/25 while conducting the facility tour, portable electric space heaters with a heating element capable of exceeding 212 degrees (100 degrees C) was located in the Lower Level office, adjacent to the elevator and exit discharge door.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.

This standard is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain the automatic emergency generator system in accordance with LSC Section 19.5.1, NFPA 99 and NFPA 110.
NFPA 101 section 19.5.1.1 states utilities shall comply with the provisions of Section 9.1.
NFPA 101 section 9.1.3 states Emergency Generators and Standby Power Systems, where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2.
NFPA 101 section 9.1.3.1 states emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
NFPA 99 section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.
NFPA 110 section 8.3.1 states that the EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
NFPA 110 section 8.3.2 states a routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
NFPA 110 section 8.3.2.1 states the operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature.
NFPA 110 section 8.3.3 states a written schedule for routine maintenance and operational testing of the EPSS shall be established.
NFPA 110 section 8.3.4 states a permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
NFPA 110 section 8.3.4.1 states the permanent record shall include the following:
(1) The date of the maintenance report.
(2) Identification of the servicing personnel.
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced.
(4) Testing of any repair for the time as recommended by the manufacturer.
NFPA 110 section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Findings Include:
During the morning and afternoon hours of 04/07/25 while touring the facility, and based upon the facility's documentation, the following items were observed regarding the Emergency Power Supply Systems (EPSSs):
1) Monthly checks did not include either specific gravity or battery conductance as required.
2) Weekly checks missing in January 2025 as well as July 2025
3) Fuel sample not provided in 2024 or from 2025.
This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an actual emergency where the use of emergency power is required.

As a result of the missing documentation relating to the Emergency Power Supply Systems (EPSSs), the facility failed to maintain its EPSSs as required by LSC Section 19.5.1, NFPA 99 and NFPA 110.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.

Based on observations and confirmed by staff interview the facility failed to ensure compliance with Article 400 and Article 590 of the 2011 edition of NFPA 70 National Electrical Code.

-Article 400.8 prohibits the use of flexible cords as a substitute for the fixed wiring of a structure.
-Article 590 states the following regarding the use of temporary wiring.

-590.3 Time Constraints:
(A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during
the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities.
(B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days
for holiday decorative lighting and similar purposes.
(C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies
and for tests, experiments, and developmental work.
(D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which
the wiring was installed.

Findings Include:

On 04/07/25 an extension cord was utilized to supplement power to the ceiling mounted television projector in the Lower level staff training room. The cord was plugged into an electrical receptacle and extended above the in-lay tiles into the projector.

As a result of the finding the facility is found to be non-compliant with Article 400 and Article 590 of the 2011 edition of NFPA 70. Flexible cords may not be used as a substitute for fixed wiring or, if allowed, must be removed upon completion of the purpose intended.

The finding was reviewed with and acknowledged by the facility's Chief Executive Officer and Director of Plant Operations during the exit conference.