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Based on observation, interview, and testing, the facility failed to ensure that required self-closing doors are maintained in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.2.2.2.7), 2012 Edition. This deficient practice affects approximately 10 residents, staff, and visitors in 2 of 9 smoke zones. This facility has a capacity of 25 and a census of 4.

Findings include:

Observation, interview, and testing on 01/21/21 at 11:21 a.m., revealed that the south leaf of the 1-1/2 hour fire rated cross corridor double doors near Room #1209 failed to positively latch within the door frame. (Door ID #118652). The Facilities Manager and Maintenance Engineer Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide a placard for the use of the K-type fire extinguisher in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (Section-10.2.2), 2011 Edition. This deficient practice affects all staff in the Kitchen. This facility has a capacity of 25 and a census of 4.

Findings include:

Observation and interview on 01/21/21 11:26 a.m., revealed the facility failed to provide a placard at the K-type fire extinguisher located in the Kitchen that states the extinguisher is to be used only after the fixed suppression system has been actuated. The Facilities Manager and Maintenance Engineer Lead verified this observation at the time of the survey process.

Based on observation, interview, and record review, the facility failed to inspect and test dampers and maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-19.4.1.1 and Section 19.4.9), 2010 Edition and National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-17.7.4.1 and Section-10.5.5.3), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4.
Findings include:
1. Observation, interview, and record review on 01/21/21 at 10:57 a.m., revealed that the facility was unable to provide documentation that the fire and smoke dampers throughout the facility had been inspected and tested within the last 6 years.
2. Observation and interview on 01/21/21 at 11:37 a.m., revealed a smoke detector installed within 3 feet of an air diffuser for the HVAC system in the Pain Management Clinic Waiting Area.
3. Observation and interview on 01/21/21 at 12:01 p.m., revealed a smoke detector installed within 3 feet of an air diffuser for the HVAC system near the 1st Floor Maintenance Elevator.
4. Observation and interview on 01/21/21 at 12:06 p.m., revealed a smoke detector installed within 3 feet of an air diffuser for the HVAC system near Room #2122.
5. Observation and interview on 01/21/21 at 12:03 p.m., revealed that the breaker (#12 located in Panel LS-6) for the fire alarm system did not contain a breaker lock which would prevent the breaker from inadvertently being turned off. The Facilities Manager and Maintenance Engineer Lead verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.1.1.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 01/21/21 at 9:42 a.m., revealed that the facility failed to conduct quarterly testing of the sprinkler system for the 1st and 3rd quarters of 2020. Interview with the Facilities Manager and Maintenance Engineer Lead stated that this was not due to the COVID pandemic, but that the testing was not conducted. The Facilities Manager and Maintenance Engineer Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure that smoke barriers are free of penetrations which would prevent the passage of smoke to an adjacent smoke compartment in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-8.5.6.2), 2012 Edition. This deficient practice affects approximately 10 residents, staff, and visitors in 2 of 9 smoke zones. This facility has a capacity of 25 and a census of 4.

Findings include:

Observation and interview on 01/21/21 at 11:36 a.m., revealed an approximate 2 inch open to the center conduit with fire alarm wiring that penetrated the smoke barrier above the lay-in ceiling tile near Room #1306. The Facilities Manager and Maintenance Engineer Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code, 2011 Edition. This deficient practice affects approximately 5 staff in 2 of 9 smoke zones. This facility has a capacity of 25 and a census of 4.

Findings include:

1. Observation and interview on 01/21/21 at 11:11 a.m., revealed a 3/4 inch flex conduit with exposed electrical wires suspended from the ceiling in the Basement above the wall paper storage area.

2. Observation and interview on 01/21/21 at 11:36 a.m., revealed an open junction box with exposed electrical wires located above the lay-in ceiling tile near Room #1306. The Facilities Manager and Maintenance Engineer Lead verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to inspect and test fire door assemblies in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-5.2.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 01/21/21 at 10:47 a.m., revealed the last annual inspection and testing of fire doors throughout the facility was conducted on 12/03/19. The Facilities Manager and Maintenance Engineer Lead verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to document testing of hospital-grade electrical receptacles in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.3.4.1.1), 2012 Edition. This deficient practice could affect 25 patients throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 01/21/21 at 11:03 a.m., revealed the facility was unable to provide documentation for testing of hospital-grade electrical receptacles upon initial installation, replacement or servicing. The Facilities Manager and Maintenance Engineer Lead verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain the emergency generators in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.3.8), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 01/21/21 at 10:30 a.m., revealed the facility was unable to provide documentation for the annual testing of fuel for both of the facility's diesel powered emergency generators. The Facilities Manager and Maintenance Engineer Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that extension cords are being used in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-10.2.4), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electric Code (Section-400.8), 2011 Edition. This deficient practice affects all staff in the Lab. This facility has a capacity of 25 and a census of 4.

Findings include:

Observation and interview on 01/21/21 at 11:32 a.m., revealed the Lab contained an unfused power strip being used to supply power to a mini refrigerator. The Facilities Manager and Maintenance Engineer Lead verified this observation at the time of the survey process.