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Based on record review and interview, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any 24-hour period in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 19 and a census of 8 patients at the time of the survey.

Findings include:

1. Record review and interview on 03/14/2023 at 10:00 a.m. of the fire alarm outage policy, revealed that the local fire department (and contact information) was not listed to contact at the beginning and conclusion of a fire watch.

2. Record review and interview on 03/14/2023 at 10:04 a.m. of the fire watch procedures of the fire alarm outage policy, revealed that the policy did not contain language to show that the fire watch designee was "dedicated" only to the fire watch.

Maintenance Staff verified these findings during the survey.

Based on record review and interview, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 19 and a census of 8 patients at the time of the survey.

Findings include:

Record review and interview on 03/14/2023 at 10:05 a.m. of the sprinkler system outage policy, revealed that the local fire department (and contact information) was not listed to contact at the beginning and conclusion of a fire watch.

Maintenance Staff verified this finding during the survey.

Based on observation, record review and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments, are smoke resisting and are positive latching as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3. This deficient practice affected approximately 3 occupants in one of seven smoke zones, as the door would not prevent the spread of fire and smoke. This facility had a capacity of 19 and a census of 8 patients at the time of the survey.

Findings include:

Observation on 03/14/2023 at 12:07 p.m., revealed a wooden door wedge being used on the Staff Locker Door in the Laboratory.

Maintenance Staff verified this finding during the survey.

Based on record review and interview, the facility failed to conduct fire drills quarterly under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 19 and a census of 8 patients at the time of survey.

Findings include:

Record review on 03/14/2023 at 9:15 a.m. of the facility's fire drill documentation, revealed first, second, and third shift drills were conducted at approximately the same time of day. Three first shift drills were conducted between 1:00 p.m. and 2:30 p.m.: on 10/31/2022 at 1:00 p.m., on 07/28/2022 at 2:10 p.m., and 01/30/2023 at 2:30 p.m. Three second shift drills were conducted between 7:00 p.m. and 8:05 p.m.: on 11/23/2022 at 7:00 p.m., 05/30/2022 at 8:00 p.m., and 02/08/2023 at 8:05 p.m. Two third shift drills were conducted between 5:05 a.m. and 6:00 a.m.: on 06/06/2022 at 5:05 a.m. and 09/21/2022 at 6:00 a.m.

Maintenance Staff verified this finding during the survey.

Based on record review and interview, this facility is not providing proper documentation of inspection and testing of fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This deficient practice affects all residents, staff, and visitors in the facility. This facility had a capacity of 19 and a census of 8 patients at the time of the survey.

Findings include:

Record review and interview on 03/14/2023 at 09:42 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. Documentation shows these inspections and testing were last completed on 05/03/2019.

Maintenance Staff said COVID interrupted the testing schedule of these doors.


NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

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 inspection by the AHJ.

5.2.3 Functional Testing.

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.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:

(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so
equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in
working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.