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Based on observation, it was determined that the facility failed to provide a safe means of egress out of the emergency exit doors. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof."

During a facility tour conducted on August 21, 2023, the facility was found to have obstructed exit pathways. The exit near the kitchen had a vending machine on the right side of the corridor leaving just over 5 feet of clearance. and the exit in the lab had an opening that was down to less than 36 inches being obstructed by machines and one refrigerator.
Employee #16 acknowledged during the site walkdown that two emergency exit doors had their pathways obstructed possibly impeding rapid exit.

Based on observation the facility failed to maintain the one-hour fire rated doors. Failing to maintain fire barriers could allow a fire to spread more rapidly through the fire barrier and give patients less time to evacuate the building.

NFPA 101 Life Safety Code, 2012, Chapter 7, Sub-Section 7.2.2.5.1.1. All inside stairs serving as an exit or exit component shall be enclosed in accordance with Section 7.1.3.2 Exits, Sub-Section 7.1.3.2.1. Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1)* The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating.
(3)* The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3).

Findings include:

Observations while on tour Aug 21-23, 2023 revealed the center firewall separation door was blocked open for traffic with a door stop due to an inoperable magnetic door holder.

Employee #4 confirmed during the facility walk down on Aug 22, 2023, that magnetic release was inoperable for the fire wall separation door and was being held open for ease of personnel flow.

Based on Observation, the facility failed to test the fire alarm system and Porter Dry Chemical system for the monthly and annual requirements for the facility. Failure to test the fire alarm system could cause harm to staff and residents during an emergency.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use". NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, "The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system". Chapter 26, Section 26.3.5.2.2 "The subsidiary facility shall be inspected at least monthly by central station personnel for the purpose of verifying the operation of all supervised equipment, all telephones, all battery conditions, and all fluid levels of batteries and generators". NFPA 72, National Fire Alarm and Signaling Code, Section14.6.2.1, Records shall be retained until the next test and fore 1 year thereafter. CMS requires 3 years.
NFPA 72 Chapter 14, section 14.2.5 Releasing Systems.
Requirements pertinent to testing the fire alarm systems initiating fire suppression system releasing functions shall be covered by 14.2.5.1 through 14.2.5.6. and must be inspected in accordance with section 14.3 Inspection which requires Monthly and Annual inspection amd service.

Findings include:

During the review of the facility's documentation on Aug 21-23, 2023, there was no documentation of monthly testing of the sprinkler system including gauge readings and valve position verification.

Employee #16 confirmed during the document review that the facility failed to provide the required documentation for a monthly sprinkler test.

Based on observation it was determined that the facility did not have written documentation of the annual inspection and testing of the facility fire doors in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's ". Failing to inspect and test fire rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code.

NFPA 80 Section 5.2* Inspections Section 5.2.1* Fire door assemblies shall be inspected and tested not less than annually , and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

Findings include:

Observation while on tour and during review of facility documentation conducted on Aug 21-23, revealed the facility did not have written records of the Annual Inspection and Testing of the fire doors throughout the facility in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's.

Management acknowledged during the exit conference that the facility failed to conduct the NFPA 80 required testing of the facility's fire doors.