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Based on observation and interview, the facility failed to perform biannual smoke sensitivity test on smoke detectors. Without this biannual testing the facility had no assurance the smoke detectors would function as required for early detection of smoke/fire. Findings:

1. During record review on 11/07/2024, it was determined the last annual fire inspection dated 05/29/2024 did not document smoke sensitivity had been performed. The last documented smoke sensitivity was performed in 2019.

2. An interview was conducted with the maintenance supervisor on 11/07/2024 and he stated he contacted the inspection company and scheduled a sensitivity test.


NFPA 72, Sec 7-3.2.1 requires that smoke detector sensitivity be checked within 1 year after installation and every alternate year thereafter.

Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system. Findings:

1. The facility records were reviewed on 11/07/2024. The most recent annual sprinkler inspection document was dated 05/29/2024. A quarterly sprinkler inspection should have been performed in the first quarter of 2024 and the third quarter of 2024, but no documentation was found for the two missing quarterly sprinkler inspections.

2. The maintenance supervisor was present during the record review on and stated he was not aware the quarterly sprinkler inspections had not been done.

Based on observation and interview, the facility failed to maintain 2 of 2 smoke barrier walls to resist the passage of smoke. Findings:

1. A tour of the facility was conducted on 11/07/2024, and the following observations were made.

South smoke wall

a) one unsealed penetration, associated with new electrical wiring was observed above the smoke doors in the attic.

West smoke wall

b) one unsealed penetration, associated with new electrical wiring was observed above the smoke doors in the attic.

2. The maintenance person was present when the smoke walls were observed on 11/07/2024, and he acknowledged the unsealed penetrations to the smoke wall.

Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames.
8.3, 19.3.7.3, 19.3.7.5

Based on record review and interview, the facility failed to conduct the routine inspections of the corridor doors throughout the facility. Findings:

1. The facility records were reviewed on 11/07/2024 and no documentation was found to show the facility had conducted routine corridor door inspections.

2. The facility CEO and maintenance supervisor were interviewed during the exit coference and they stated they are checking the corridor doors but they did not document.


Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessments were not completed and do not exist.

On 11/07/2024 the surveyor asked the CEO for the EES and Medical Gas building system risk assessments. She stated they were not aware of the requirement but would ensure they will be completed.

Based on observation, record review and staff interview, the facility failed maintain appropriate documentation for the required monthly generator under load testing as required by NFPA 99. In the event of an electrical outage, the facility could not be assured the generator would function properly without performing the required inspections and testing. Findings:

1. The facility's records were reviewed on 11/07/2024. No documentation was found to show the facility was performing the required monthly 30 minute under load testing of the generator.

2. The maintenance supervisor stated the generator automatically runs at times but he did not know if it ran under load for 30 minutes monthly.