San Luis Valley Regional Medical Center

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 47557 Based on the life safety code recertification survey conducted 4/22/2025 through 4/23/2025, the facility failed to comply with regulations set forth in the Life Safety Code. The Condition of Participation §482.41 Physical Environment was out of compliance. A-0700 - The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. The facility failed to comply with the regulations set forth for Life Safety. Deficiencies were cited under the Life Safety Code deficiencies K-0345, K-0353, K-0372, K-0521, K-0700, K-0918, K-0924. See survey event ID R1VY21 for full details of the cited deficiencies.”

“A recertification LSC survey was completed on 4/23/2025. Seventeen deficiencies were cited. § 482.41 PHYSICAL ENVIRONMENT The Initial Comments (ID Tag 0000) are informational only and are intended only to represent the facility’s general characteristics. This survey, conducted in accordance with the Federal Register, Section 42, CFR Part 482.41(b), included a full Life Safety Code® survey pursuant to the facility electing to give up its deemed status and place its facilities under the purview of the Colorado Department of Public Health and Environment. This three-story structure, hereinafter referred to as the Main Hospital, and licensed for 49 beds at the time of this survey, is an addition to an original structure constructed in 1938 with additions made in 1963, 1958, 1960, 1968, 1998 and 2004. Although this structure has a mixture of construction types, the lowest fire-resistive rating of the Main Hospital structure is Type II (222). The original hospital structure, separated from the Main Hospital by a two-hour separation, is a single-story, Type II (222) structure with a partial basement. The original hospital structure is protected by an automatic sprinkler system, and it is used as a typical business occupancy containing offices, conference rooms, and records storage. In addition to the original hospital structure, there is another fire-resistive structure adjacent to the Main Hospital. This structure, too, is separated from the Main Hospital by a two-hour fire separation. This adjacent structure, although owned by the hospital, is leased and operated independently as a community clinic. The first floor of the Main Hospital houses the emergency room, MRI, X-Ray, cafeteria, office, OB-GYN and Pediatric care facilities. The second floor houses maternity, ambulatory surgical, and surgery facilities. The third floor houses critical care, and ICU facilities. Additionally, this facility has a helipad on the roof. This survey, conducted April 22-23, 2025, inspected the Main Hospital for compliance with Chapter 19, “Existing Health Care Occupancies,” of the 2012 edition of the National Fire Protection Association (NFPA) Life Safety Code® (NFPA 101), and other publications as referenced. In addition to the main hospital campus, there are two Offsite Campus Locations (OCLs) operated under the purview of the San Luis Valley Regional Medical Center license. These are business occupancies, one of which is referred to as the Physicians’ Services (PS) building, also known as the Stuart Street facility, located in Alamosa, the other, located in Monte Vista, CO, is referred to as the Monte Vista facility. The PS building, located in Alamosa, is a “slab-on-grade,” two-story, Type II (000) structure, which is partially sprinklered in the older section. This older section was utilized in the past for surgical and other medical procedures; it is now utilized as office space and records storage. Also, the PS building has a hydraulically driven elevator. The OCL in Monte Vista, is a non-sprinklered, “slab-on-grade,” fully-sheathed, two-story, Type V (000) structure. This survey evaluated the PS building in Alamosa and the OCL in Monte Vista for compliance with Chapter 39, “Existing Business Occupancies,” of the 2012 edition of the National Fire Protection Association (NFPA) Life Safety Code (NFPA 101), and other publications as referenced. As constructed and protected, these three facilities will meet the prescriptive requirements of the 2012 edition of NFPA 101 with all deficiencies contained herein corrected. This survey concluded April 23, 2025 with an Exit Conference with the Director of Compliance, and the Maintenance Director.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 47557 Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Stair 4 Delayed egress egress door 3rd floor (no signage or alarm) (non-compliant IAW NFPA 101) Door corrections need to come in for plan review 2. Stair 4 Delayed egress baby ward (non-compliant IAW NFPA 101) 3. ED department stairway 4 needs an eye to disable the maglock NFPA 101 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: Locks complying with 19.2.2.2.5 shall be permitted. *Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. *Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted. Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted. Approved existing door-locking installations shall be permitted. 19.2.2.2.5 Door-locking arrangements shall be permitted in accordance with either 19.2.2.2.5.1 or 19.2.2.2.5.2. 19.2.2.2.5.1* Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 47557 Through observation during the survey and staff interview, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by: 1.Exit signs in the lobby need to be listed: Lobby, Admin, Imaging Hallway 2.Photoluminescent signs need light for charging signs throughout the facility’s exits NFPA 101 7.10.5 Illumination of Signs. 7.10.5.1* General. Every sign required by 7.10.1.2, 7.10.1.5, or 7.10.8.1, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode. 7.10.7 Internally Illuminated Signs. 7.10.7.1 Listing. Internally illuminated signs shall be listed in accordance with ANSI/UL 924, Standard for Emergency Lighting and Power Equipment, unless they meet one of the following criteria: (1)They are approved existing signs. (2)They are existing signs having the required wording in legible letters not less than 4 in. (100 mm) high. (3)They are signs that are in accordance with 7.10.1.3 and 7.10.1.6. 7.10.7.2* Photoluminescent Signs. The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source, as determined by the authority having jurisdiction. The charging light source, shall be of a type specified in the product markings. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 47557 Based on a record review and staff interview, it was determined that facility did not follow installation and testing requirements for the fire alarm system IAW NFPA 72 for past construction project. 1.UnPermitted work conducted without AHJ approval/final testing for the MRI remodel project NFPA 72 14.4.1 System Testing. 14.4.1.1 Initial Acceptance Testing. 14.4.1.1.1 Initial acceptance testing shall be performed as required in 14.4.1.1.1.1 through 14.4.1.1.1.2. 14.4.1.1.1.1 All new systems shall be inspected and tested in accordance with the requirements of Chapter 14. 14.4.1.1.1.2 The authority having jurisdiction shall be notified prior to the initial acceptance test. 14.4.1.2* Reacceptance Testing. 14.4.1.2.1 Reacceptance testing shall be performed as required in 14.4.1.2.1.1 through 14.4.1.2.1.4. 14.4.1.2.1.1 When an initiating device, notification appliance, or control relay is added, it shall be functionally tested. 14.4.1.2.1.2 When an initiating device, notification appliance, or control relay is deleted, another device, appliance, or control relay on the circuit shall be operated. 14.4.1.2.1.3 When modifications or repairs to control equipment hardware are made, the control equipment shall be tested in accordance with Table 14.4.2.2, items 1(a) and 1(d). 14.4.1.2.1.4 When changes are made to site-specific software, the following shall apply: (1)All functions known to be affected by the change, or identified by a means that indicates changes, shall be 100 percent tested. (2)In addition, 10 percent of initiating devices that are not directly affected by the change, up to a maximum of 50 devices, also shall be tested and correct system operation shall be verified. (3)A revised record of completion in accordance with 10.18.2.1 shall be prepared to reflect these changes. 14.4.1.2.2 Changes to all control units connected or controlled by the system executive software shall require a 10 percent functional test of the system, including a test of at least one device on each input and output circuit to verify critical system functions such as notification appliances, control functions, and off-premises reporting. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 47557 Based on a record review and staff interview, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. 1. Annual Fire Alarm Report - Need to clarify if all heat detection was tested for the elevator and elevator pits - Detectors that were missed during the remodel need to be tested - Emergency Control Functions need to be tested IAW NFPA 72 (Smoke/Fire Dampers) - Semi-annual visual inspection not documented on the report NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ’ s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes. 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. 23. Emergency control functions Emergency control functions (i.e., fan control, smoke damper operation, elevator recall, elevator power shutdown, door holder release, shutter release, door unlocking, etc.) shall be tested by operating or simulating alarm signals. Testing frequency for emergency control functions shall be the same as the frequency required for the initiating device that activates the emergency control function. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 47557 Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101. 1. Sprinkler in OR area not flush with the ceiling 2. Woman ’ s imaging sprinkler head damaged 3. Missing sprinkler cover in office 123 4. Sprinkler in freezer missing escutcheon 5. Hydro sign blank for sprinkler riser in basement 6. Sprinkler pipe in the basement has wires attached 7. Sprinkler coverage needs to be evaluated in the basement, multiple sprinkler heads obstructed by HVAC work, Records storage room: protection and sprinkler not in compliance with NFPA 99 15.10 and 15.11 8. Stairwell between 3rd floor of the hospital and the leased space is not sprinklered IAW NFPA 13 9. ATS room bump out not sprinklered in accordance with NFPA 13 and facility’s life safety plans 10. Penthouse area not protected with an approved sprinkler system NFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 25 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. NFPA 13 8.15.3.2 Noncombustible Construction. 8.15.3.2.1 In noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. NFPA 101 19.3.5 Extinguishment Requirements. 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. NFPA 99 15.10* Compact Storage. Compact storage shall be protected by sprinklers in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 15.11 Compact Mobile Storage. 15.11.1 Rooms with compact mobile storage units greater than 50 ft2 (4.65 m2) shall be protected as a hazardous area in accordance with the applicable building code, NFPA 101, Life Safety Code, or fire code. 15.11.2 Smoke detection shall be installed above compact mobile storage units greater than 50 ft2 (4.65 m2) in accordance with NFPA 72. 15.11.3* Compact mobile storage units greater than 50 ft2 (465 m2) shall be protected by automatic sprinklers in accordance with NFPA 13. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 47557 Based on observation and staff interview, it was determined that the facility failed to maintain corridor doors in accordance with NFPA 101. 1. Room 2112 doors need to be self-closers and on mag locks if they want to be held open. Staff area door should be a rated door 2. The drop-down door in the admin area needs to be maintained or removed NFPA 101, 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 Protectives, except as otherwise specified in this Code. NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13/4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes NFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. NFPA 101 4.6.12.3* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 47557 Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain fire/smoke barriers in accordance with NFPA 101. 1.Ortho Electrical Closet Penetrations in closet (Need to know listing of material used in closet) NFPA 101 8.3.1.2* Fire barriers shall comply with one of the following: (1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. (2)The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. 8.3.4 Opening Protectives. 8.3.4.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. 8.3.4.2* The fire protection rating for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2, except as otherwise permitted in 8.3.4.3 or 8.3.4.4. Table 8.3.4.2 was revised by a tentative interim amendment (TIA). These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 47557 Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code and NFPA 105 1. Fire Damper report showed multiple dampers not reachable or failed, with no repair reports available (invoice available but no repair report) NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service Phase I key recall and smoke detector automatic recall, firefighter’s service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This Standard is not met as evidenced by: 47557 Based on a record review and staff interview, it was determined that the facility failed to maintain the elevator components and devices in accordance with NFPA 101. 1.No Elevator monthly com checks (Facility working on plan to update system) NFPA 101 9.4.6 Elevator Testing. 9.4.6.1 Elevators shall be subject to periodic inspections and tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. 9.4.6.2 All elevators equipped with fire fighters ’ emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. 9.4.6.3 The elevator inspections and tests required by 9.4.6.1 shall be performed at frequencies complying with one of the following: (1)Inspection and test frequencies specified in Appendix N of ASME A17.1/CSA B44, Safety Code for Elevators and Escalators (2) Inspection and test frequencies specified by the authority having jurisdiction These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“Operating Features - Other CFR(s): NFPA 101 Operating Features - Other List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included in Form CMS-2567. This Standard is not met as evidenced by: 47557 Based on a record review and staff interview, it was determined that the facility failed to maintain the Rooftop Landing Facilities in accordance with the Life Safety Code NFPA 418. Two portable foam extinguishers, each having a rating of 20-A:160-B, not available in lieu of foam suppression system Unable to provide training documentation for firefighting operations NFPA 418 7.7 Fire Protection.The fire protection requirements in Section 7.7 shall be permitted to be modified where a fire risk assessment, as outlined in Chapter 4, identifies that an alternative means of protection is acceptable as outlined in the fire risk assessment. 7.7.1 General. A foam fire protection system with either a fixed discharge outlet(s) in accordance with 7.7.2 or a hose line(s) in accordance with 7.7.3 shall be designed and installed to protect the rooftop landing pad, unless otherwise permitted by the following: (1) A foam fire protection system shall not be required for heliports, helistops, vertiports, or vertistops, located on open parking structures or buildings that are not normally occupied. (2) For A-1 heliports, helistops, vertiports, and vertistops, two portable foam extinguishers, each having a rating of 20-A:160-B, shall be permitted to be used to satisfy the requirement of 7.7.1. (3) Where foam extinguishers per 7.7.1(2) are not available, approved extinguishers with a 20-A:160B:C rating shall be permitted. (4) Where approved, alternative fire protection systems shall be provided in accordance with Chapter 4. 7.7.1.1 Where trained personnel are not available, fixed fire protection outlet(s) shall be provided. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 47557 Based on documentation review and staff interview, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by: 1.No documentation available to show hospital grade receptacles have been inspected IAW with performance data NFPA Standard: NFPA 99 Health Care Facilities Code (2012) 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 47557 Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidenced by the following: 1. Generator Documentation Missing - No weekly Inspections documented - Documents state specific gravity testing; however, batteries are sealed - Monthly transfer switch time is not logged 8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendations Instruction manuals Minimum requirements of this chapter The authority having jurisdiction 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”

“Gas Equipment - Testing and Maintenance Requi CFR(s): NFPA 101 Gas Equipment - Testing and Maintenance Requirements Anesthesia apparatus are tested at the final path to patient after any adjustment, modification or repair. Before the apparatus is returned to service, each connection is checked to verify proper gas and an oxygen analyzer is used to verify oxygen concentration. Defective equipment is immediately removed from service. Areas designated for servicing of oxygen equipment are clean and free of oil, grease, or other flammables. Manufacturer service manuals are used to maintain equipment and a scheduled maintenance program is followed. 11.4.1.3, 11.5.1.3, 11.6.2.5, 11.6.2.6 (NFPA 99) This Standard is not met as evidenced by: 47557 Based on a record review and staff interview, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code and NFPA 99. 1. Med Gas: Shows deficiencies on report (Recommend reaching out to MedGas to get a documented response for what these affect, DFPC is unable to determine distinct life hazard based on the report) 2. Oxygen outside needs coverage NFPA 99 5.1.1.4 An existing system that is not in strict compliance with the provisions of this code shall be permitted to be continued in use as long as the authority having jurisdiction has determined that such use does not constitute a distinct hazard to life. 11.6.5.4 Cylinders stored in the open shall be protected as follows: (1)Against extremes of weather and from the ground beneath to prevent rusting (2)During winter, against accumulations of ice or snow (3)During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Director of Compliance and the Maintenance Director at the exit conference.”