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Based on record review, observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5 and 9.7.5, NFPA 25 - 2011 edition, Sections 5.2.1, 5.2.1.1.1, 13.2.7.2, 13.3.2.1.1, 13.6.1, 13.6.1.1.1, 13.4.2.1, 14.2.1 & Table 5.1.1.2, 13.1.1.2. These deficient practices could affect all 13 patients and an undetermined number of staff and visitors.

Findings include:

1. On 04/18/2023 at 10:35 am, record review of sprinkler system inspection reports by USA Fire Protection revealed no quarterly inspections for the 4th quarter of 2022 and 1st quarter of 2023. The most recent inspection by USA Fire Protection was conducted on 08/03/2022. Staff G indicated that the contract with USA Fire Protection had expired in September 2022 and that no new vendor had been contracted to perform these inspections.

2. On 04/18/2023 at 11:25 am, observation revealed in soiled linen closet room 162 a 2' x 2' ceiling tile was removed from the metal ceiling grid. This opening in the ceiling did not duplicate the tight conditions that were used in the sprinkler UL certification test.

These deficient practices were confirmed by Staff G at the time of discovery.

Based on observation and interview, the facility failed to provide regular inspection of portable fire extinguishers in accordance with NFPA 101 (2012 edition), 19.3.5.12 and 9.7.4.1; and NFPA 10 (2010 edition), 7.2.1.2 This deficient practice could affect an undetermined number of patients, staff and visitors.

Findings include:

On 04/18/2023 at 11:58 am, observation of the K-type portable fire extinguisher preventive maintenance tag on the main kitchen K-type fire extinguisher revealed no required 30-day inspection of this extinguisher had been done during March 2023.

This deficient practice was confirmed by Staff G at the time of discovery.

Based on record review and interview, the facility did not conduct fire drills as required by NFPA 101 (2012 edition), 19.7.1.6., to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency could affect all 13 patients and an undetermined number of staff and visitors.

Findings include:

On 04/18/2023 at 10:45 am, record review revealed that there was no record of any fire drills or fire drill training being conducted during any shift of the 3rd quarter of 2022. Staff G indicated he was off on medical leave.

This deficient practice was confirmed by Staff G at the time of discovery.