Alliance Healthcare System, Inc.

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 20543 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.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 20543 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.”

“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: 20543 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.”

“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: 20543 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.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This Standard is not met as evidenced by: 20543 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 ...).”