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Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2.1.3. This deficient practice affects one of three smoke zones and could affect staff within the affected zone. The facility had a capacity of 17 residents and a census of 2.

Findings include:

1. Observation on 02/27/2023 at 10:49 a.m., revealed the Pantry in the Kitchen exceeded 50 square feet in size and did not contain a self-closure device on the door. This room contained storage of canned as well as dry goods.

The Maintenance Supervisor confirmed this observation at the time of the survey process.

Based on record review, observation, and interview, the facility failed to test and maintain the fire alarm system within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.6.1.3 and NFPA Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 14.4.2.2 and 14.4.5, smoke damper testing was completed on 08/27/2020 by Fire Door Solutions and documented three smoke dampers were not located. This deficient practice could affect residents, staff, and visitors in the affected smoke compartments. The facility had a capacity of 17 and a census of 2 residents at the time of the survey.

Findings include:

Record review on 02/27/2023 at 9:19 a.m., revealed the facility paperwork contained documentation from Fire Door Solutions stating the facility did not have dampers located in three required locations. Fire damper inspection records from 08/27/2020 listed dampers missing Hallway, First Admin Office, and Other. Interview of the Maintenance Supervisor revealed the testing company could not locate the three dampers. Documentation revealed all other dampers were located and working.

The Maintenance Supervisor acknowledged these findings during the survey process.

Based on record review and interview, the facility failed to conduct fire drills 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 17 and a census of 2 residents at the time of survey.

Findings include:

Record review on 02/27/2023 at 9:54 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. Two first shift drills were conducted between 9:18 a.m. and 9:45 a.m.: on 04/29/2022 at 9:18 a.m. and 11/05/2022 at 9:45 a.m. Four second shift drills were conducted between 3:08 p.m. and 4:32 p.m.: on 03/30/2022 at 4:32 p.m., 06/28/2022 at 3:13 p.m., at 09/22/2022 4:28 p.m., and 12/28/2022 at 3:08 p.m. Three third shift drills were conducted between 2:00 a.m. and 2:30 a.m.: on 02/23/2023 at 2:00 a.m., on 05/22/2022 at 2:30 a.m., and 08/29/2022 at 2:00 a.m. The Maintenance Director verified the documentation during the survey process.

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 residents, staff, visitors in the facility. This facility had a capacity of 17 and a census of 2 residents at the time of the survey.

Findings include:

Record review on 02/27/2023 at 9:44 a.m., revealed the facility could not provide full documentation of annual inspection and testing of fire and/or smoke door assemblies within the facility. Interview of Maintenance Staff revealed the facility conducts regular door inspections and documents them as completed, but that documentation did not contain verification of the 11 minimum items as required by code.

Maintenance Staff confirmed the documentation at the time of the survey.


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.