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Based on visual observation the facility failed to provide exit signage for all required exits. Exit signs provide a route for occupants to reach safety. The deficient practice had the potential to affect 31 of 31 residents.
2 of 10 exits have signage that is deficient.

Findings:

During the facility tour, on 10/5/2021 between the hours of 10:30am to 2:00pm it was observed that both exterior fenced in areas had doors/gates that blended in with the fencing. These gates/doors do not have signage and the path of egress travel is not obvious

Interview with the Plant Operations Director revealed the facility was not aware that additional exit signage was required.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 17 of 17 residents.

Findings:

During the facility tour, on 10/5/2021 between the hours of 3:00pm to 6:00pm it was observed that the exterior type V000 construction had been extended along the exterior of the building leading to the marked exit from the fenced in area. The sprinkler system was only provided to protect the initial portion of the V000 construction.

Interview with the maintenance personal revealed the facility was not aware the automatic sprinkler system was not complete.

Based on visual observation the facility failed to assure that the automatic sprinkler system has supervised valves that will sound a local alarm if closed. A direct result, of the fire alarm system being notified of the emergency, is protection of life and property. This deficiency has the potential to affect 31 of 31 residents.

Findings:

During the facility tour, on 10/5/2021 between the hours of 10:30am to 2:00pm it was observed that the backflow preventer valves were not provided with electronic supervision. This was also observed on the valves to and from the water storage tank. Only one valve at the water storage tank was locked. During record review of submitted drawings for the sprinkler system it was found that the drawings indicated electronic tampers being installed on the backflow preventer.

Interview with the Plant Operation Director revealed the facility was not aware that the valves on the sprinkler system were not supervised by the fire alarm system.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 31 of 31 residents.

Findings:

During the facility tour, on 10/5/2021 between the hours of 10:30am to 2:00pm it was noted that the last sprinkler system annual inspection was performed on 9/30/2020. It was also noted that the sprinkler system had not been inspected as per NFPA 25. It was noted that valves were not supervised and/or chained and locked. Also it was not verified if the water storage tank piping had been provided with freeze protection and/or low temperature alarms.

Interview with the Plant Operation Director revealed the facility was not aware that the annual and quarterly inspections had not been properly conducted on the automatic sprinkler system.

Based on visual observation the facility failed to assure that the fire extinguishers were inspected and tested in accordance with the Life Safety Code and NFPA 10. Fire extinguishers are available to extinguish small fire or smoke emergencies. This deficient practice could potentially affect 17 of 17 residents.

Findings:

During the facility tour and the record review, on 10/5/2021 between the hours of 3:00pm to 6:00pm it was observed that the extinguisher in the generator building had not been provided with an annual inspection in several years. It was also noted the extinguisher was an ABC and this building also had a flammable liquid dispenser present.

Interview with the maintenance personnel revealed the facility was not aware that the annual and/or monthly inspection on the fire extinguishers had not been conducted.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect of residents.
2 of 15 smoke barriers were deficient.

Findings:

During the facility tour, on 10/5/2021 between the hours of 10:30am and 2:00pm it was observed that multiple penetrations were present in the rated assemblies above the drop ceiling in the medical records room, the front wall of the multipurpose room, and above the fire rated doors entering the activity/dining room.

Interview with the Plant Operations Director revealed the facility was not aware of unsealed penetration.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 17 of 17 residents.
1 of 2 smoke barriers were deficient.

Findings:

During the facility tour, on 10/5/2021 between the hours of 3:00pm to 6:00pm it was observed that the 1 hour rated smoke barrier had a penetration that was unsealed and other penetrations sealed with a non rated caulk in the med room above the drop ceiling.

Interview with the maintenance personnel revealed the facility was not aware of unsealed penetration.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another. The deficient practice had the potential to affect 17 of 17 residents.
1 of 2 smoke barriers were deficient.

Findings:

During the facility tour, on 10/5/2021 between the hours of 3:00pm to 6:00pm it was observed that the cross corridor doors in the 1 hour rated smoke barrier appeared to be damaged and did not fully close. The vision glass in these doors also appeared to not be rated.

Interview with the maintenance personnel revealed the facility was not aware of the cross corridor doors were not creating a smoke resistive seal when closed.

Based on visual observation, the facility failed to assure that the policy on smoking required all smoking areas to be supplied with a metal, self-closing container. Cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion. This deficient practice could potentially affect 31 of 31 residents.

Findings:

During the facility tour, 10/5/2021 between the hours of 10:30am to 2:00pm it was observed that in both fenced in outdoor areas containers were provided to put cigarette butts in. However cigarette butts were littered all around both outdoor areas.

Interview with the Plant Operations Director revealed the facility was not aware the containers in the smoke areas were not being utilized.

Based on visual observation the facility failed to assure that installed fire doors were inspected and maintained. The fire doors restrict the movement of fire from one compartment to another. NFPA 80:5.2.3.5.2 states, "As a minimum, the following items shall be verified: (1) Labels are clearly visible and legible. (2) No open holes or breaks exist in surfaces of either the door or frame. (3) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (4) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (5) No parts are missing or broken. (6) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (7) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (8) If a coordinator is installed, the inactive leaf closes before the active leaf. (9) Latching hardware operates and secures the door when it is in the closed position. (10) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (11) No field modifications to the door assembly have been performed that void the label. (12) Meeting edge protection, gasketing and edge seals, where required, are inspected to verify their presence and integrity. (13) Signage affixed to a door meets the requirements listed in 4.1.4." The deficient practice had the potential to affect of residents.

Findings:

During the facility tour and record review, on 10/5/2021 between the hours of 10:30am to 2:00pm it was noted that numerous fire rated doors had been identified as needing repairs to meet the requirements of NFPA 80. The identified deficiencies for the fire doors had not been corrected.

Interview with the Plant Operation Director revealed the facility was aware that the fire doors had not been repaired.

Based on visual observation and record review the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110 and that the monthly testing program on the emergency generator was conducted and documented. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 17 of 17 residents.
4 of 4 months were deficient.

Findings:

During the facility tour and record review, on 10/7/2021 between the hours of 3:00pm to 6:00pm it was noted that no weekly or monthly inspections/testing was performed and/or documented.


Interview with the maintenance personnel revealed the facility was aware that all documentation was not complete regarding the inspection/testing of the emergency generator.

Based on visual observation and record review the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. NFPA 110:7.13.3 states, "The authority having jurisdiction (AHJ) shall be given advance notification of the time at which the acceptance test is to be performed so that the authority can witness the test." In cases of a power outage the emergency generator powers essential life safety equipment for the facility. 5 of 12 months were deficient.

Findings:

During the facility tour and record review, on 10/5/2021 between the hours of 10:30am to 2:00pm the following was noted:

1) It was noted that the weekly testings were not performed and/or documented for several weeks through approximately 5 months.
2) The AHJ did not receive a submittal for the new generator and the generator has not been provided with an acceptance test and/or the AHJ was not notified of the acceptance test.
3) No remote manual stop for the generators had been provided within view of the generator.


Interview with the Plant Operations Director revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator.