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Based on observations and review, the facility failed to annually inspect and test fire door assemblies in accordance with the NFPA 80 (2010 edition) section 5.2 (CMS S&C Letter 17-38). This deficiency affected all smoke compartments and all residents in the facility on the day of survey.



Findings include:



On 8/14/24 at 12:40 PM, observation and document review revealed the facility was unable to produce documentation for annual inspection of three (3) stairwells fire doors on the 2nd Floor of the facility. Observation also revealed the three (3) stairwells fire doors on the 2nd Floor of the facility were in poor, limited functioning condition.

Based on observations, the facility failed to protect hazardous area in accordance with NFPA 101 sections 19.3.2.1 and 8.4.2. The deficient practice affected all smoke compartments and patients in facility on the day of survey.



Findings include:



On 8/14/24 at 3:40 PM, observation revealed the damage and inoperable Boiler Room/ Mechanical Closet contain on the 1st Floor of the facility.

Based on observations, the facility failed to have a properly installed fire alarm control

panel as per NFPA 101 section 9.6.4 and 9.6.6. The deficient practice affected the entire facility on the day of survey.

Findings include:

On 8/14/24 at 1:35 PM, observation revealed the fire alarm system lacked a remote annunciator panel in a constantly monitored location of the facility (ex. Nurses station or receptionist desk ...). Observation also revealed no smoke detection and horn strobes in between the two (2) new installed traffic control doors in the corridors on the 2nd floor of the facility.

Based on observations the facility failed to provide the required 30-minute fire resistance rating for smoke barrier walls in accordance with NFPA 101 sections 19.3.7.3, 8.5, 8.5.6. This deficiency affected the entire facility on day of survey.

On 8/14/24 at 1:10 PM, observation revealed open, unsealed penetrations all in smoke barrier walls in the Laundry Area of the facility.

Based on observations, the facility failed to provide all the generator required components as in accordance to NFPA 110 section 5.6.6 and NFPA 99 section 6.4.1.1.17. The deficient practice affected the entire facility on the day of survey.

Findings include:

On 8/14/24 at 1:30 PM, observation revealed the generator lacked a complete remote annunciator panel in a constantly monitored location of the facility (ex. Nurses station or receptionist desk ...).