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Based upon record review and interview, the facility failed to hold fire drills at different times of the day for three 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. This facility has a capacity of 25 with a census of 7.

Findings include:

Staff interview and review of the facility fire drill documentation on 12/15/14 at 2:25 p.m., showed all of the third shift drills were conducted from 3:00 a.m. to 3:30 a.m. for the first three quarters of 2014. Maintenance Staff A verified the documentation.

NFPA standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. 2000 NFPA 101, 19.7.1.2

Based on observation and record review, the facility failed to provide a properly tested and maintained fire alarm system. All of the facility was directly affected by the deficient practice; a total of 18 smoke compartments and approximately 7 residents and staff members. The facility has 25 certified beds and at the time of the survey the census was 7residents.

Findings include:

Observation and review of the inspection records for the fire alarm system on 12/15/14 at 14:15 p.m., revealed the the last two inspections dated June 2014 and October 2013, were over the required 6 month interval. Maintenance Staff A confirmed observations during the survey process.

NFPA standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7-3.2. and listed as required by NFPA 72, 7-5.2.2

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This can affect the operation of the heads by delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire in two of eighteen smoke zones. The census was 7 residents with a certified capacity of 25.

Findings include:

Observation and interview on 12/16/14 from 9:15 a.m. to 12:20 p.m., revealed missing escutcheon plates for the sprinklers in the Soiled Linen room (1) across from Room 2100I and in the corridor (1) by room 2852. This observation was verified with Maintenance Staff A.


-NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. NFPA 25, 1-11.3

Based upon record review and interview, the facility failed to hold fire drills at different times of the day for three 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. This facility has a capacity of 25 with a census of 7.

Findings include:

Staff interview and review of the facility fire drill documentation on 12/15/14 at 2:25 p.m., showed all of the third shift drills were conducted from 3:00 a.m. to 3:30 a.m. for the first three quarters of 2014. Maintenance Staff A verified the documentation.

NFPA standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. 2000 NFPA 101, 19.7.1.2

Based on observation and record review, the facility failed to provide a properly tested and maintained fire alarm system. All of the facility was directly affected by the deficient practice; a total of 18 smoke compartments and approximately 7 residents and staff members. The facility has 25 certified beds and at the time of the survey the census was 7residents.

Findings include:

Observation and review of the inspection records for the fire alarm system on 12/15/14 at 14:15 p.m., revealed the the last two inspections dated June 2014 and October 2013, were over the required 6 month interval. Maintenance Staff A confirmed observations during the survey process.

NFPA standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7-3.2. and listed as required by NFPA 72, 7-5.2.2

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This can affect the operation of the heads by delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire in two of eighteen smoke zones. The census was 7 residents with a certified capacity of 25.

Findings include:

Observation and interview on 12/16/14 from 9:15 a.m. to 12:20 p.m., revealed missing escutcheon plates for the sprinklers in the Soiled Linen room (1) across from Room 2100I and in the corridor (1) by room 2852. This observation was verified with Maintenance Staff A.


-NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. NFPA 25, 1-11.3