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Based on obeservation and staff interview, the facility failed to maintain stairways and smokeproof enclosures per NFPA 101 (2012 edition), Life Safety Code, sections 19.2.2.3, and 7.2.2.5.3.1. This deficient finding could have an isolated impact on residents within the facility.

Findings include:

On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that construction materials and equipment were being stored under the egress stairwell in the southwest corner of the building.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to implement a fire alarm out-of-service policy per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.6. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 03/06/2025 between 09:00 AM and 1:00 PM, it was revealed by review of available documentation that the fire alarm system out-of-service policy was incomplete and did not list the appropriate safety measures to follow, including having a fire watch policy, and a list of contacts that need to be contacted about the situation.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to install the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.5.1 and 9.7.1.1 and NFPA 13 (2010 edition), The Standard for the Installation of Sprinkler Systems, section 8.15.5.3. These deficient findings could have an isolated impact on the residents within the facility.

Findings include:

On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that there was no sprinkler head installed in the following elevator equipment rooms: Elevator Equipment Room 2 in the basement, and the 2nd Floor Elevator Equipment Room in the patient room area across the hallway from the nurses station.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Saftey Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.2.1.1.2(5), and 5.2.2.2. These deficient findings could have a patterned impact on residents within the facility.

Findings include:

1. On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that sprinkler heads in the main kitchen dish room, and in the laundry area soiled linen room were covered and lint and debris.

2. On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that a blue wire was on the sprinkler pipe in Mechanical Room R8.

An interview with Maintenance Director verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to implement a fire sprinkler out-of-service policy per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.5.1, and 9.7.5, and NFPA 25 (2010 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 15.5.2. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 03/06/2025 between 09:00 AM and 1:00 PM, it was revealed by review of available documentation that the sprinkler system out-of-service policy was incomplete and did not list the appropriate safety measures to follow, including having a fire watch policy, and a list of contacts that need to be contacted about the situation.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke barriers per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.3, and 8.5.6.2. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by observation that fire caulking was missing from around a blue wire that was penetrating the smoke barrier wall in Mechanical Room R8.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills per NFPA 101 (2012 edition), Life Safety Code sections 19.7.1.6. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that a fire drill was conducted during the third shift of the 3rd quarter of 2024.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain fire door assemblies and hardware per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.6, and 4.6.12.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.4.2(7). This deficient finding could have an isolated impact on residents within the facility.

Findings include:

On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed that the coordinator above the fire barrier doors leading to the 2nd floor lobby for Elevator 3 was not adjusted properly preventing the doors from closing as designed.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to maintain the emergency generator per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.3.4, 8.4.1, 8.4.2, and 8.4.9. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

1. On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing a four (4) hour load bank test has been completed within the last 36 months for the generator.

2. On 03/06/2025 between 9:00 AM and 1:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that weekly and monthly generator operational inspection and testing had been occurring prior to July 18, 2024.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.