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Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 25. This was evidenced by:

1) fire sprinkler gauges dated 2015 need to be replaced
2) The pre-action system needs 3 year full trip testing completed
3) Flow meter gauge dated 2016 due annually for calibration prior to testing
4) 5-year internal on backflow

Based on a record review it was determined that the facility failed to maintain the fire sprinkler system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.

NFPA 101, 9.7.5 Maintenance and Testing.
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.

NFPA 25, Chapter 5 Sprinkler Systems
Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25, Chapter 13 Common Components and Valves
Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25 8.3.3.1.4
Where 8.3.3.1.2.2 or 8.3.3.1.2.3 is used, the flowmeter shall be adjusted immediately prior to conducting the testing in accordance with the manufacturer ' s instructions.

NFPA 25 13.4.2.1 Inspection.
Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 54. This was evidenced by:

1) Gas valves on the dryer(s) not rated for more than 2000 feet elevation need high-elevation gas valves

NFPA 54 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

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

1) No carbon monoxide detector installed in "Main Lobby" with with gas fireplace

NFPA 101 Heating, Ventilating, and Air Conditioning (101 19.5.2.3(2)(f)): Electrically supervised carbon monoxide detection in accordance with Section 9.8 shall be provided in the room where the fireplace is located.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 99. This was evidenced by:

1) The facility does not inspect wet locations every 6 months as required by NFPA 99 6.3.2.2.8.5.
2) The facility does not meet the record-keeping requirements per NFPA 99 6.3.4.2

NFPA 99 6.3.2.2.8.5(B)(4)
(B) Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested as follows:
(1) When first installed
(2) Where there is evidence of damage
(3) After any repairs
(4) At intervals not exceeding 6 months

NFPA 99
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99. This was evidenced by:

1) Natural ventilation is not sized adequately for the oxygen tank supplying the medical gas room. Mechanical Ventilation will need to be added to this room per NFPA 99 9.3.7.5.3

NFPA 99
9.3.7.5.2.1 Natural ventilation shall consist of two nonclosable louvered openings, each having an aggregate free opening area of at least 155 cm 2/35 L (24 in. 2/1000 ft 3)of the fluid designed to be stored in the space and in no case less than 465 cm 2 (72 in.2).

9.3.7.5.3 Mechanical Ventilation.
9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction.
9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft 3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm).
9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) of the floor and adjacent to the cylinder or containers.
9.3.7.5.3.4 Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system.
9.3.7.5.3.5 Dedicated exhaust systems shall not be required, provided that the system does not connect to spaces that contain combustible or flammable materials.
9.3.7.5.3.6 The exhaust duct material shall be noncombustible.
9.3.7.5.3.7 A means of make-up air shall be provided according to one of the following:(1) Air shall be permitted via noncombustible ductwork to be transferred from adjacent spaces, from outside the building, or from spaces that do not contain combustible or flammable materials via noncombustible ductwork(2) Air shall be permitted to be transferred from a corridor under the door up to the greater of 24 L/sec (50 cfm) or15 percent of the room exhaust in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.(3) Supply air shall be permitted to be provided from any building ventilation system that does not contain flammable or combustible vapors.
9.3.7.6 Discharge from the natural and mechanical ventilation systems shall be sited by a minimum separation distance in accordance with NFPA 55, Compressed Gases, and Cryogenic Fluids Code.
9.3.7.7 A storage room shall maintain a temperature not greater than 52°C (125°F).
9.3.7.8 A transfer or manifold room shall maintain a temperature not greater than 52°C (125°F) and not less than -7°C(20°F).

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.