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Based on interview and record review, the facility did not provide and maintain complete documentation or provide 100% semi-annual testing of the fire alarm system as required by NFPA 72. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the fire alarm system did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 25 and a census of 7 residents at the time of the survey.

Findings include:

1. Record review and interview on 3-21-19, of the fire alarm inspection forms dated 1-25-19 revealed the device list was incomplete. The device list was missing the dampers. According to the facility's semi-annual fire alarm testing reports, 100% of the fire alarm system was not tested, and the documentation did not include all of the required testing and information required by NFPA 72.

2. Record review and interview on 3-22-19, of the fire alarm inspection of the Stratford Clinic the inspection tag was dated 4-21-2017 by Mid West Alarm.

3. Observations on 3-22-19 at 11:12 a.m., a ceiling air diffuser was located within three feet of the smoke detector in the South West Hall of the E.R.

These deficient practices were confirmed by Maintenance Staff A at the time of exit.

Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all staff in eleven of eleven smoke zones. The facility had a capacity of 25 and a census of 7 at the time of survey.

Findings include:

1. Observation on 3-22-19 at approximately 10:39 a.m., revealed that in the Administration Records room 1 of 4 sprinkler heads was miss the eschutian ring. Corrected during the inspection.

2. Observation on 3-22-19 at approximately 10:49 a.m., revealed that the sprinkler head over the Kitchen Huddle board was covered with dust.

3. Observation on 3-22-19 at approximately 11:21 a.m., revealed the sprinkler head over the Catscan was covered with dust.

4. Observation on 3-22-19 at approximately 11:38 a.m., revealed that 3 of 8 sprinkler heads in the Laundry Storage area were covered with dust.

5. Observation on 3-22-19 at approximately 11:42 a.m., revealed the sprinkler head over the south exit sign in the Laboratory was covered with dust.

6. Observation and interview on 3-22-19 at 11:42 a.m., of the facility's sprinkler system revealed that all of the gauges at the dry sprinkler system riser and wet system rise were newer in appearance and did not have dates written on their faces. No other documentation was provided showing the gauge had been tested as required. The Maintenance Supervisor stated Viking Automatic Sprinklers, Inc. did not replace the gauges after the install in 2009. The Maintenance Supervisor verified this finding at the time of the survey.

Based on interview and record review, this facility did not assure that a 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 ten hours in any twenty-four hour period. 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 affected all occupants of the building. This facility had a capacity of 25 and a census of 7 residents at the time of the survey.

Findings include:

1. Record review on 3-21-19, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period. The policy did not include phone numbers or call list of the appropriate Authorities Having Jurisdiction. The plan was missing the contacts and contact numbers for D.I.A., Fire Marshal at the discovery of impairment and after the sprinkler system is back in service.

2. Record review on 3-21-19, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address the supervisors in the areas to be affected have notification of the sprinkler impairment.

3. Record review on 3-21-19, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address a tag impairment system during sprinkler impairment.

4. Record review on 3-21-19, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address the interruption of the water supply and equipment failures.

5. Record review on 3-21-19, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to include areas or buildings involved have been inspected and increased risks determined.

6. Record review on 3-21-19, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address the recommendations have been submitted to management or the property owner.

7. Record review on 3-21-19, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service. The policy failed to address System Leakage, Interruption, Equipment failure and Ruptured Piping.

8. Record review on 3-21-19, of the fire watch procedures revealed the facility did not
have a complete policy regarding the procedures to be taken in the event that the
sprinkler system was out of service. The policy failed to address the designation of an
Impairment Coordinator.


Administrative Staff A confirmed the findings during the exit conference.

Based on observation, record review and interview, the facility failed to maintain the K Type fire extinguisher in the kitchen. One extinguisher in the kitchen was affected by the deficient practice of not being easily accessible. This facility had a capacity of 25 and a census of 7 residents at the time of the survey.

Findings include:

Observation of the K Type fire extinguisher on 3-22-19, at 11:45 a.m., revealed the K Type extinguisher on the east wall of the Kitchen was not provided with a placard stating "in case of appliance fire use this extinguisher only after fixed suppression system has been actuated.". This deficient practice was confirmed by Maintenance Staff A at the time of discovery.

Based on observation and interview, the facility is not assuring that two of two smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.7.3 and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects 25 residents, staff, and visitors in two of eleven smoke zones. The facility has a capacity of 25 with a census of 7.

Findings include:

Observation and interview on 3-22-19 at 11:10 a.m., revealed the smoke barrier penetration in the North 2 hour fire rated wall next to #1508 above the lay in tile. It appeared that the manufactured pass through was pull away from the 2 hour wall. According to the facility layout, this was a required barrier. The Environmental Services Director and Administrator verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, by allowing the use of non-approved electrical devices or adapters within the facility. This deficient practice affects one resident in one of eleven smoke zones. The facility has a capacity of 25 and a census of 7.

Findings include:

1. Observation and interview on 3-22-19 at 10:52 a.m., revealed a tan drop cord used for a crock pot in the Kitchen serving area. Maintenance Staff (A) removed at the time of the survey.

2. Observations on 3-22-19 at 10:30 a.m., revealed the residential stove located in the Physical Therapy Transitional Room failed to be equipped with a lock out switch.

Maintenance Director A stated the room is used as a transition room for those residents preparing to leave the facility. The Maintenance Director confirmed these findings.

Based on interview and record review, the facility failed to provide a complete fire plan. The fire plan did not include information on all of the types of fire extinguishers and range hood and how to operate them. The deficient practice affected one of five smoke zones. This facility had a capacity of 25 and a census of 7 residents at the time of the survey.

Findings include:

Record review on 3-21-19, the plan did not address the types of fire extinguishers and how to use them or information about the range hood. The plan did not assign an individual to call 911. The plan also did not address too activate the manual fire alarm system no matter the size of the fire.

Interview with one kitchen staff verified they did not know how to activate the hood suppression system.

Based on record review and interview, the facility failed to document the inspections, tests, exercising, and operation of the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4. The deficient practice affects all smoke compartments of the building and all of the residents, staff, and visitors. The facility has a capacity of 25 and a census of 7.

Findings Include:

1. Record review and interview on 3-21-19, revealed the facility failed to maintain proper documentation of weekly generator inspections. The facility failed to documented the generator oil and fuel during the weekly inspections.

2. Record review and interview on 3-21-19, revealed the facility failed to maintain proper documentation of monthly load tests for the facility's generator. The facility had not documented the generator transfer times.

Maintenance Staff (A) verified this documentation.