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Based on observation it was determined the facility failed to maintain the smoke/fire resistive rating of corridor walls in three of several locations on the second floor.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}...."

Findings Include:

On July 30, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager and Senior Building Engineer observed conduit penetrations or holes in the corridor walls located by the following three areas on the second floor.

1. Green Kitchen.
2. Elevators East Side of the building.
3. Electrical room by the Nursing Unit.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site at the exit survey by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat could cause harm to the patients.

Based on observation it was determined the facility failed to maintain the second floor corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted...."

Findings Include:

On July 30, 2015 the surveyor, accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager and Senior Building Engineer the following corridor doors would not positively latch when tested to close three of three times or were missing the latching mechanisms for the doors.

1. Co-ed bathroom by the front nurses station.
2. Seclusion rooms used for medical and wheelchair etc; storage both doors were missing the latching mechanisms in the doors.
3. The soiled utility room (hazardous room ) was missing the self closing device on the door.
During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site at the exit survey by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation it was determined the facility failed to fill penetrations in two of three smoke barriers on the second floor.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ½ hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose...."

Findings include:

On July 30, 2015 the surveyor, accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager and Senior Building Engineer observed unsealed penetrations in the smoke barriers located by the following areas on the second floor.

1. Haven Administration and by the Director of Nursing Office.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site at the exit survey by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients.

Based on record review and interview with Haven Senior Horizon Staff, Property Management and Building Engineers it was determined the facility failed to:

1. conduct and perform fire drills under simulated emergency conditions for the Senior Haven Horizon Hospital third shifts.

2. sound the fire alarm on the second floor for the first and second shifts and sound a coded announcement on the third shift for the Havens Senior Horizon Hospital.

3. conduct fire drills for the following shifts: no documentation was found or shown to the surveyor while on site that the following fire drills were completed.

1. First quarter, 2015 first and second shifts.
2. Second quarter, second shift.

In addition: Based on observation and interview with Haven Senior Horizon Staff, Property Management and Building Engineers it was determined the facility failed to have a written plan (fire procedures manuals) for protection of of all persons in the event of a fire for their evacuation from the building when necessary, a copy of the written plan at the front and back nurses stations was missing during the survey.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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 Life Safety Code Chapter 19, Section 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "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 a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center...."

Findings include:

On July 30, 2015 and July 31, 2015 the surveyor, accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager reviewed the Havens Senior Horizon fire drills. The surveyor reviewed and observed the fire drill documentation and noted the third shift fire drills were not conducted and performed under simulated emergency conditions on the second floor.

The 2014 and 2015 fire drills were conducted by the facility Security Officers. The Security Officers according to the documentation asked questions from the 2nd floor staff and had the staff explain the emergency procedures. The fire drills did not indicate the fire drills were simulated and conducted under emergency simulated conditions per the 2000 Life Safety Code.

In addition: the fire alarm for the first and second shifts was being sounded on the first floor as well as the coded announcement for the third shifts by Security staff as annotated on the fire drill reports and not sounded on the second floor for the fire drills for 2014 and 2015.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Senior Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager Human Resources Manager.

Failure to actually perform and conduct the fire drills in accordance with the 2000 NFPA 101 Life Safety Code under simulated emergency conditions could result in harm to the patients in time of fire or emergency.

Based on interview with Haven Senior Horizon Staff, Property Management and Building Engineers it was determined the facility failed to test and document the five year flow test of the facilities wet standpipe systems.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5. "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." . Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 25 1998 Edition Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems...."

NFPA 25 1998 Edition Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 3 Standpipe and Hose Systems.

NFPA 25 1998 Edition Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 3 Standpipe and Hose Systems. Section 3-3.2 Hydrostatic Tests Section 3-3.2.1 "Hydrostatic tests conducted every five years on dry standpipe systems and dry portions of wet standpipe systems...."

NFPA 25 Section 3-3.1 Flow Tests "A flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply still adequately provided's the design pressure at the required flow. A flow test shall be conducted every 5 years...."

NFPA 25 Section 3-2 Inspection. Section 3-2.1 "Components of standpipe and hose systems shall be visually inspected quarterly or as specified in Table 3-1 and 3-2.3...."

Findings include:

On July 31, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager, Building Engineers and Senior Building Engineer asked to see the documented evidence indicating the wet standpipe systems were tested every five years.

The Property Management staff advised the surveyor there was no documentation of the five year test completed on the standpipes for the facility. There was no current or past records shown to the surveyor while on site this test was completed.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Senior Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failure to test and maintain the wet standpipe system could result in a malfunction during a fire and could cause harm to the patients.

Based on observation it was determined the facility failed to test maintain the fire pump weekly, and maintain the pump from excessively leaking from the fire pump packing glands.

"NFPA 101 Life Safety Code, 2000, Chapter, 21, Section 21.7.6 "Maintenance and Testing (See 4.6.12).... "

Chapter 4, Section 4.6.12.1 "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction...."

"NFPA 25 1998 Edition, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 5, Section 5-3.2.1, " A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes...."

"NFPA 25 1998 Edition, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 5 Section 5-3.2.4.1 Pump Test Procedure. (b)
Check the pump packing glands for slight discharge. (c) adjust gland nuts if necessary...."

Findings Include:

On July 31, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager and Building Engineers reviewed the Monthly fire pump testing documentation for 2014 and 2015. The Month of July 2015 all four weeks indicated the fire pump was run for 3 minutes and not ten minutes.

In addition: upon observation of the facility fire pump, the packing glands were excessively leaking water at a steady rate of flow and not a slight discharge, one drop at a time.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failure to conduct the ten minute weekly fire pump tests and maintain the fire pump packing glands could allow the fire pump to fail during a fire emergency. This could cause harm to patient and staff if the fire pump is not working during a fire.

Based on observation it was determined the facility failed to inspect four of several portable ABC fire extinguishers on a Monthly basis for June 2015 on the second floor.

NFPA 101, Life Safety Code, Chapter 19, Section 19.3.5.6, "Portable Fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1." Section 9.7.4.1,"Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers. NFPA 10, Chapter 4, Section 4-3.1, "Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30 day intervals...Section 4-3.4.2, "At least monthly, the date the inspection was performed, and the initials of the person performing the inspection shall be recorded...."

Findings include:

On July 30, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager and Senior Building Engineer observed the following four ABC fire extinguishers did not have monthly checks for June of 2015 documented on the fire extinguisher Annual tags or on separate records.

1. Office Kitchen supplies room.
2. Fire extinguisher cabinet marked # 32 in one of the corridors of the second floor.
3. Nurses station 1 and 2.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site at the exit survey by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failing to maintain ABC fire extinguishers if needed in time of a fire could cause injury to the patients in time of a fire.

Based on interview with the Haven Senior Horizon staff, Property Management staff and Building Engineers it was determined the facility failed to comply with NFPA 90A Section
3-4.7 by not inspecting, servicing and maintaining the fire dampers fusible links or fire smoke dampers in the air ducts at least every six years per S&C 10-04.

"NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.2 Heating Ventilating and Air Conditioning Section 19.5.2.1 "Heating, ventilating, and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications." Section 9.2.1 "Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." "Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A," "Standard for Installation of Air Conditioning and Ventilating Systems...."

"NFPA 90A, 1999 Edition Standard for the Installation of Air-Conditioning and Ventilating Systems, Section 3-4.7 Maintenance, states at least every 4-years, fusible links (where applicable) shall be removed; all dampers shall be operated that they fully close; the latch, if provided shall be checked; and moving parts shall be lubricated as necessary...."

Findings include:

On July 31, 2015 the surveyor, accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager and Building Engineers the surveyor asked to see the the documented evidence indicating the fusible links or fire smoke dampers were serviced and maintained every six years. No current or past documentation was provided to the surveyor while on site that the fusible links or fire smoke dampers were serviced at least every six years per S&C 10-04 Waiver to Allow the Hospitals to use the NFPA 6 year Testing interval.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failing to maintain and inspect the fire smoke dampers or fusible links every six years could effect patients and staff in time of a fire.

Based on observation it was determined the facility failed to provide a medical gas cylinder storage room free of combustible materials, and mount the light switch five feet off the floor.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet..." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...."

"NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage...."

Findings include:

On July 30, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager, Senior Building Engineer observed the second floor oxygen storage room. The oxygen bottles E-cylinders, a total of three were stored in the Physical Exam room which had medical supplies, storage of plastics and equipment etc: The light switch was observed not to be five feet from the floor when measured.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients. Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.

Based on record review and interview with Haven Senior Horizon Staff, Property Management and Building Engineers it was determined the facility failed to document the required Monthly testing under load 30 minutes, and transfer times ten seconds or less, for two emergency generators.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year...Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On July 30 and 31, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager, Building Engineers and Senior Building Engineer reviewed the generator test records. The surveyor asked to see the documented evidence indicating the generators were tested Monthly under load 30 minutes and transfer times were documented for ten seconds or less.

No documentation evidence was shown to the surveyor while on site indicating the Monthly under load test for 30 minutes and transfer times was completed upon review of the generator records prior to July 2015.

Gen Tech did quarterly testing three times in 2014 and 2015 but the forms did not indicate a Monthly load test was completed. The Gen Tech form reviewed noted the load transfer test was not completed or declined to be done.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: The Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failure to test the emergency generator under load for 30 minutes and document the transfer time from normal power to emergency power 10 seconds or less and under could result in harm to the patients during emergency system power failures.

Based on observation and testing of the two emergency generators by the Building Engineers it was determined the facility failed to maintain both generator alarm annunciators for both generators at the first floor security desk.

NFPA 99 "Standard for Health Care Facilities."Chapter #3 Electrical Systems, Section
3-4.1.1.14 Requirements for Safety Devices. Section 3-4.1.1.15 Alarm Annunciators."A remote annunciators storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station.(see NFPA 70,National Electrical code, 700-12). The annunciators shall indicate alarm conditions of the emergency or auxiliary power source as follows:

(a) Individual visual signals shall indicate the following:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning
(b) Individual signals plus a common audible signal to warn of an engine-generator alarm condition shall
indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature(below those required in (3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3 hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed...."

Findings include:

On July 30, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager, Building Engineers and Senior Building Engineer and Security Officers observed the generator alarm annunciators panels for both generators were not working when tested by the Building Engineers.

The Engineers tried the test buttons to illuminate the visual signals for both alarm annunciator panels but they did not work when tested. The Engineers ran both generators on July 30 and 31, 2015 but the alarm annunciators did not receive a signal at either panel.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Senior Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager Human Resources Manager.

Failure to maintain the alarm annunciator panels in time of a power outage or other emergency could result in harm to the patients in time of a fire or emergency.

Based on interview with the Haven Senior Horizon Staff, Property Management Staff and Building Engineers it was determined the facility failed to test the fire fighter service, monthly elevator re-call on the East side elevators for Haven Senior Horizon Hospital.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.3, "Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. Section 9.4.6 'Elevator Testing.' Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators...Includes firefighters service phase 1 key recall and smoke detector automatic recall, firefighters service phase 11 emergency in car key operation, machine room smoke detectors, and elevator lobby smoke detectors...."

Findings include:

On July 31, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager Building Engineers asked to see the documented evidence that the monthly elevator fire fighter service re-call test was done on a Monthly basis.

The facility did provide any documentation evidence to the surveyor while on site to indicate any testing prior to June 2015 fire fighter service elevator re-call was done on a monthly basis.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Fire fighter service is critical during emergencies and failing to test the elevators Monthly may cause harm to the patients if not tested.

Based on observation it was determined the facility failed to maintain the smoke/fire resistive rating of corridor walls in three of several locations on the second floor.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}...."

Findings Include:

On July 30, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager and Senior Building Engineer observed conduit penetrations or holes in the corridor walls located by the following three areas on the second floor.

1. Green Kitchen.
2. Elevators East Side of the building.
3. Electrical room by the Nursing Unit.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site at the exit survey by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat could cause harm to the patients.

Based on observation it was determined the facility failed to maintain the second floor corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted...."

Findings Include:

On July 30, 2015 the surveyor, accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager and Senior Building Engineer the following corridor doors would not positively latch when tested to close three of three times or were missing the latching mechanisms for the doors.

1. Co-ed bathroom by the front nurses station.
2. Seclusion rooms used for medical and wheelchair etc; storage both doors were missing the latching mechanisms in the doors.
3. The soiled utility room (hazardous room ) was missing the self closing device on the door.
During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site at the exit survey by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation it was determined the facility failed to fill penetrations in two of three smoke barriers on the second floor.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ½ hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose...."

Findings include:

On July 30, 2015 the surveyor, accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager and Senior Building Engineer observed unsealed penetrations in the smoke barriers located by the following areas on the second floor.

1. Haven Administration and by the Director of Nursing Office.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site at the exit survey by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients.

Based on record review and interview with Haven Senior Horizon Staff, Property Management and Building Engineers it was determined the facility failed to:

1. conduct and perform fire drills under simulated emergency conditions for the Senior Haven Horizon Hospital third shifts.

2. sound the fire alarm on the second floor for the first and second shifts and sound a coded announcement on the third shift for the Havens Senior Horizon Hospital.

3. conduct fire drills for the following shifts: no documentation was found or shown to the surveyor while on site that the following fire drills were completed.

1. First quarter, 2015 first and second shifts.
2. Second quarter, second shift.

In addition: Based on observation and interview with Haven Senior Horizon Staff, Property Management and Building Engineers it was determined the facility failed to have a written plan (fire procedures manuals) for protection of of all persons in the event of a fire for their evacuation from the building when necessary, a copy of the written plan at the front and back nurses stations was missing during the survey.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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 Life Safety Code Chapter 19, Section 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Response to alarms
4. Isolation of fire
5. Evacuation of immediate area
6. Evacuation of smoke compartment
7. Preparation of floors and building for evacuation
8. Extinguishment of fire.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "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 a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center...."

Findings include:

On July 30, 2015 and July 31, 2015 the surveyor, accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager reviewed the Havens Senior Horizon fire drills. The surveyor reviewed and observed the fire drill documentation and noted the third shift fire drills were not conducted and performed under simulated emergency conditions on the second floor.

The 2014 and 2015 fire drills were conducted by the facility Security Officers. The Security Officers according to the documentation asked questions from the 2nd floor staff and had the staff explain the emergency procedures. The fire drills did not indicate the fire drills were simulated and conducted under emergency simulated conditions per the 2000 Life Safety Code.

In addition: the fire alarm for the first and second shifts was being sounded on the first floor as well as the coded announcement for the third shifts by Security staff as annotated on the fire drill reports and not sounded on the second floor for the fire drills for 2014 and 2015.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Senior Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager Human Resources Manager.

Failure to actually perform and conduct the fire drills in accordance with the 2000 NFPA 101 Life Safety Code under simulated emergency conditions could result in harm to the patients in time of fire or emergency.

Based on interview with Haven Senior Horizon Staff, Property Management and Building Engineers it was determined the facility failed to test and document the five year flow test of the facilities wet standpipe systems.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5. "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." . Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 25 1998 Edition Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems...."

NFPA 25 1998 Edition Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 3 Standpipe and Hose Systems.

NFPA 25 1998 Edition Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 3 Standpipe and Hose Systems. Section 3-3.2 Hydrostatic Tests Section 3-3.2.1 "Hydrostatic tests conducted every five years on dry standpipe systems and dry portions of wet standpipe systems...."

NFPA 25 Section 3-3.1 Flow Tests "A flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply still adequately provided's the design pressure at the required flow. A flow test shall be conducted every 5 years...."

NFPA 25 Section 3-2 Inspection. Section 3-2.1 "Components of standpipe and hose systems shall be visually inspected quarterly or as specified in Table 3-1 and 3-2.3...."

Findings include:

On July 31, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager, Building Engineers and Senior Building Engineer asked to see the documented evidence indicating the wet standpipe systems were tested every five years.

The Property Management staff advised the surveyor there was no documentation of the five year test completed on the standpipes for the facility. There was no current or past records shown to the surveyor while on site this test was completed.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Senior Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failure to test and maintain the wet standpipe system could result in a malfunction during a fire and could cause harm to the patients.

Based on observation it was determined the facility failed to test maintain the fire pump weekly, and maintain the pump from excessively leaking from the fire pump packing glands.

"NFPA 101 Life Safety Code, 2000, Chapter, 21, Section 21.7.6 "Maintenance and Testing (See 4.6.12).... "

Chapter 4, Section 4.6.12.1 "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction...."

"NFPA 25 1998 Edition, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 5, Section 5-3.2.1, " A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes...."

"NFPA 25 1998 Edition, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems. Chapter 5 Section 5-3.2.4.1 Pump Test Procedure. (b)
Check the pump packing glands for slight discharge. (c) adjust gland nuts if necessary...."

Findings Include:

On July 31, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager and Building Engineers reviewed the Monthly fire pump testing documentation for 2014 and 2015. The Month of July 2015 all four weeks indicated the fire pump was run for 3 minutes and not ten minutes.

In addition: upon observation of the facility fire pump, the packing glands were excessively leaking water at a steady rate of flow and not a slight discharge, one drop at a time.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failure to conduct the ten minute weekly fire pump tests and maintain the fire pump packing glands could allow the fire pump to fail during a fire emergency. This could cause harm to patient and staff if the fire pump is not working during a fire.

Based on observation it was determined the facility failed to inspect four of several portable ABC fire extinguishers on a Monthly basis for June 2015 on the second floor.

NFPA 101, Life Safety Code, Chapter 19, Section 19.3.5.6, "Portable Fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1." Section 9.7.4.1,"Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers. NFPA 10, Chapter 4, Section 4-3.1, "Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30 day intervals...Section 4-3.4.2, "At least monthly, the date the inspection was performed, and the initials of the person performing the inspection shall be recorded...."

Findings include:

On July 30, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager and Senior Building Engineer observed the following four ABC fire extinguishers did not have monthly checks for June of 2015 documented on the fire extinguisher Annual tags or on separate records.

1. Office Kitchen supplies room.
2. Fire extinguisher cabinet marked # 32 in one of the corridors of the second floor.
3. Nurses station 1 and 2.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site at the exit survey by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failing to maintain ABC fire extinguishers if needed in time of a fire could cause injury to the patients in time of a fire.

Based on interview with the Haven Senior Horizon staff, Property Management staff and Building Engineers it was determined the facility failed to comply with NFPA 90A Section
3-4.7 by not inspecting, servicing and maintaining the fire dampers fusible links or fire smoke dampers in the air ducts at least every six years per S&C 10-04.

"NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.2 Heating Ventilating and Air Conditioning Section 19.5.2.1 "Heating, ventilating, and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications." Section 9.2.1 "Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." "Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A," "Standard for Installation of Air Conditioning and Ventilating Systems...."

"NFPA 90A, 1999 Edition Standard for the Installation of Air-Conditioning and Ventilating Systems, Section 3-4.7 Maintenance, states at least every 4-years, fusible links (where applicable) shall be removed; all dampers shall be operated that they fully close; the latch, if provided shall be checked; and moving parts shall be lubricated as necessary...."

Findings include:

On July 31, 2015 the surveyor, accompanied by the Director of Risk Management, Property Manager, Assistant Property Manager and Building Engineers the surveyor asked to see the the documented evidence indicating the fusible links or fire smoke dampers were serviced and maintained every six years. No current or past documentation was provided to the surveyor while on site that the fusible links or fire smoke dampers were serviced at least every six years per S&C 10-04 Waiver to Allow the Hospitals to use the NFPA 6 year Testing interval.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failing to maintain and inspect the fire smoke dampers or fusible links every six years could effect patients and staff in time of a fire.

Based on observation it was determined the facility failed to provide a medical gas cylinder storage room free of combustible materials, and mount the light switch five feet off the floor.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet..." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...."

"NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage...."

Findings include:

On July 30, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager, Senior Building Engineer observed the second floor oxygen storage room. The oxygen bottles E-cylinders, a total of three were stored in the Physical Exam room which had medical supplies, storage of plastics and equipment etc: The light switch was observed not to be five feet from the floor when measured.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients. Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.

Based on record review and interview with Haven Senior Horizon Staff, Property Management and Building Engineers it was determined the facility failed to document the required Monthly testing under load 30 minutes, and transfer times ten seconds or less, for two emergency generators.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year...Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On July 30 and 31, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager, Building Engineers and Senior Building Engineer reviewed the generator test records. The surveyor asked to see the documented evidence indicating the generators were tested Monthly under load 30 minutes and transfer times were documented for ten seconds or less.

No documentation evidence was shown to the surveyor while on site indicating the Monthly under load test for 30 minutes and transfer times was completed upon review of the generator records prior to July 2015.

Gen Tech did quarterly testing three times in 2014 and 2015 but the forms did not indicate a Monthly load test was completed. The Gen Tech form reviewed noted the load transfer test was not completed or declined to be done.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: The Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Failure to test the emergency generator under load for 30 minutes and document the transfer time from normal power to emergency power 10 seconds or less and under could result in harm to the patients during emergency system power failures.

Based on observation and testing of the two emergency generators by the Building Engineers it was determined the facility failed to maintain both generator alarm annunciators for both generators at the first floor security desk.

NFPA 99 "Standard for Health Care Facilities."Chapter #3 Electrical Systems, Section
3-4.1.1.14 Requirements for Safety Devices. Section 3-4.1.1.15 Alarm Annunciators."A remote annunciators storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station.(see NFPA 70,National Electrical code, 700-12). The annunciators shall indicate alarm conditions of the emergency or auxiliary power source as follows:

(a) Individual visual signals shall indicate the following:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning
(b) Individual signals plus a common audible signal to warn of an engine-generator alarm condition shall
indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature(below those required in (3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3 hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed...."

Findings include:

On July 30, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager, Building Engineers and Senior Building Engineer and Security Officers observed the generator alarm annunciators panels for both generators were not working when tested by the Building Engineers.

The Engineers tried the test buttons to illuminate the visual signals for both alarm annunciator panels but they did not work when tested. The Engineers ran both generators on July 30 and 31, 2015 but the alarm annunciators did not receive a signal at either panel.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Senior Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager Human Resources Manager.

Failure to maintain the alarm annunciator panels in time of a power outage or other emergency could result in harm to the patients in time of a fire or emergency.

Based on interview with the Haven Senior Horizon Staff, Property Management Staff and Building Engineers it was determined the facility failed to test the fire fighter service, monthly elevator re-call on the East side elevators for Haven Senior Horizon Hospital.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.3, "Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. Section 9.4.6 'Elevator Testing.' Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators...Includes firefighters service phase 1 key recall and smoke detector automatic recall, firefighters service phase 11 emergency in car key operation, machine room smoke detectors, and elevator lobby smoke detectors...."

Findings include:

On July 31, 2015 the surveyor accompanied by the Director of Risk Management, Property Manager and Assistant Property Manager Building Engineers asked to see the documented evidence that the monthly elevator fire fighter service re-call test was done on a Monthly basis.

The facility did provide any documentation evidence to the surveyor while on site to indicate any testing prior to June 2015 fire fighter service elevator re-call was done on a monthly basis.

During the exit conference on July 31, 2015 the above findings were again acknowledged per a phone call by the Senior Vice President of Operations and Vice President of Clinical Quality, and acknowledged on site by the following staff: Director of Risk Management, Property Manager, Assistant Property Manager and Human Resources Manager.

Fire fighter service is critical during emergencies and failing to test the elevators Monthly may cause harm to the patients if not tested.