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Based on observation and record review during the course of the survey conducted on April 15, 2022, it was determined the facility failed to maintain emergency lighting in accordance with NFPA 101, section 19.2.9 and section 7.9. The following evidenced this:

1) No documentation for annual EM generator load bank test. Facility must perform annual load bank due to not meeting monthly minimum load.

The deficiency has the potential to affect occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

During the review of the facility records, with the staff on April 15, 2022, documentation was not available to confirm that the facility had kitchen-hood-exhaust-system inspections and cleaning schedule as required by NFPA 96. The following evidenced this:

1) Kitchen hood suppression system was tagged deficient (yellow tag).

The Cooking Facilities deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference.

The maintenance director acknowledge the lack of cleaning and inspection of the system during record review.

NFPA 96, Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surface becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire system shall be inspected by a properly trained, qualified and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 11.4

Based on record review, observation and staff interview during the course of the survey conducted on April 15, 2022, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101, section 19.3.5.1, 9.7, 9.7.5, NFPA 25 and NFPA 13. The following evidenced this:

1) MRI trailer suppression system was inoperable.
2) Escutcheon plate in kitchen storage needs to be reset.
3) Sprinkler head above kitchen wash station was corroded and needs to be replaced/cleaned.
4) Unable to verify if the sprinkler head near heater in oxygen room was a high temp head.

The fire sprinkler deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference.

Facility is currently on fire watch until system has been repaired.

NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observation, staff interview and record review on April 15, 2022, it was determined that the facility failed to maintain all portable fire extinguishers as required by Life Safety 101 and NFPA 10. The following evidenced this:

1) Fire extinguisher needs hung in room A145 and MRI trailer.

Maintenance Director acknowledged the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

The fire extinguisher deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference.

Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers.

Based on observation and staff interview during the course of the survey conducted on April 15, 2022, it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 19.3.7.3 including 8.5. The following evidenced this:

1) Penetration near conduit in receiving room rated wall.

Maintenance director acknowledged the deficiency during a tour of the facility.

The smoke barrier deficiency has the potential to affect all occupants, who might include staff and visitors in all associated compartments; items were discussed during the survey and again during the exit conference.

Life Safety Code Section 19.3.7.3, in part, smoke barrier walls constructed in accordance with Section 8.5 with a minimum of 1/2-hour fire resistive rating. Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

Based on record review and staff interview during the survey on April 15, 2022, it was determined the facility failed to conduct fire drills in accordance with NFPA 101, 19.7.1. The following evidenced this:

1) No documentation for current fire drills.

The fire drill deficiencies have the potential to affect all occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Based on observation and staff interview during the survey on April 15, 2022, it was determined that the facility failed to maintain electrical equipment in accordance with NFPA 70, NFPA 99 Ch 10 and NFPA 101. This was evidenced by the following:

1) Boiler room has fridge and microwave plugged into extension cord.

The electrical equipment deficiency has the potential to affect all occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference.