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Based on observation and interview the facility fails to insure that the facility's automatic sprinkler system is maintained in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all residents in two of six smoke zones including the dining area. The facility has a capacity of 48 and census of 33 at the time of the survey

Findings include:

During the survey on January 7, 2019 the following is observed:

1. During the survey, it was observed that there are multiple sprinkler heads that are dirty or obstructed by plastic.

Staff M1 was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 2011 NFPA 25, 5.2.1.1.1

Review of the following NFPA Standard revealed: Any sprinkler that shows signs of any of the following shall be replaced:

(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the sprinkler manufacturer
2011 NFPA 25, 5.2.1.1.2

Review of the following NFPA Standard revealed: The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:
(1) For protected facilities having under 300 sprinklers-no fewer than 6 sprinklers
(2) For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers

Based upon observation and staff interview the facility is not ensuring that doors to a corridor close and latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine and smoke products and to properly defend occupants in place, affecting approximately all patients and any visitors or staff in all smoke zones. The facility has a capacity of 48 with a census of 33 at the time of this survey.

Findings include:

During the survey conducted on January 7, 2019, it is observed:

1.) It was observed that there are several patient room doors that have approximately a 1 inch wide penetration running the whole vertical length of the door on the latch side.

Staff M1 was present and acknowledged the findings at the time of discovery.

NFPA Standard: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Based on record review and staff interview the facility fails to provide a documented maintenance and testing program for electrical receptacles and circuit breakers. This deficient practice prevents the facility from ensuring that electrical receptacles and circuit breakers are maintained and tested as required by NFPA 99 Health Care Facilities and could adversely affect all patients in all smoke zones. The facility has a capacity of 48 with a census of 33 patients at the time of the survey.

Findings include:

During the survey on January 7, 2019 the following is revealed:

1. There is no documented annual inspection and testing of the physical integrity of electrical receptacles in resident care rooms at bed locations.

2. There is no documented annual inspection and exercising of main and feeder circuit breakers.


Staff M1 was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: The physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). 2012 NFPA 99, 6.3.3.2.1 through 6.3.3.2.4

Review of the following NFPA Standard revealed: A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. 2012 NFPA 99, 6.3.4.2.1.1 and 6.3.4.2.1.2

Review of the following NFPA Standard revealed: Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations. 2012 NFPA 99, 6.4.4.1.2.1

Review of the following NFPA Standard revealed: A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. 2012 NFPA 99, 6.4.4.2

Based on record review and staff interview the facility failed to assure the generator is inspected and tested in accordance with NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all residents in 4 of 4 smoke zones. The facility has a capacity of 48 and census of 33 at the time of the survey.

Findings include:

During record review conducted on January 7, 2019 of the facility's generator inspection testing and maintenance records revealed that the annual fuel test is overdue..

Staff M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1

Review of the following NFPA Standard revealed: A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer. 2010 NFPA 110, 8.3.4, 8.3.4.1

Review of the following NFPA Standard revealed: A fuel quality test shall be performed at least annually using tests approved by ASTM standards. 2010 NFPA 110, 8.3.8