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Based on record review and interview, the facility failed to maintain the inspection and servicing schedule of the commercial cooking suppression system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.2.3 and NFPA Standard 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 11.2. This deficient practice affects one of five smoke zones and could affect all staff in the Kitchen. The facility had a capacity of 17 and a census of 2 at the time of the survey.

Findings include:

During inspection of the facility on 06/01/2023 at 9:32 a.m., revealed the facility failed to maintain the Kitchen hood suppression system. The facility failed to have the fire-extinguishing system nozzles cover the cooking surface. The Maintenance Supervisor verified the documentation during the survey.

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 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. The facility had a capacity of 17 and a census of 2 residents at the time of survey.

Findings include:

Record review on 06/01/2023 at 9:32 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 9:55 a.m. and 10:30 a.m.: on 01/26/2023 at 9:55 a.m. and 04/21/2023 at 10:30 a.m. Two second shift drills were conducted between 3:05 p.m. and 3:15 p.m.: on 12/29/2022 at 3:05 p.m., and 03/29/2023 at 3:15 p.m. Three third shift drills were conducted between 4:50 a.m. and 5:20 a.m.: on 02/27/2023 at 5:20 a.m., on 05/27/2022 at 4:50 a.m., and 11/29/2022 at 5:15 a.m. The Maintenance Director verified the documentation during the survey process.

Based on record review and interview, the facility failed to maintain and test essential electrical system (EES) circuitry as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. The deficient practice affects all of the smoke compartments throughout the building and all occupants. The facility had a capacity of 17 and a census of 2 residents at the time of the survey.

Findings include:

Record review on 06/01/2023 at 10:44 a.m., revealed the facility was unable to provide documentation of inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers within the last year. The last documentation of inspection or exercising had been done 05/24/2022 by Ziegler Cat. Maintenance Staff confirmed this finding at the time of the survey.

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 failing to use general precautions with power strips and surge protectors and allowing the use of non-approved electrical devices or adapters within the facility. These deficient practices affect staff in one of five smoke compartments. The facility had a capacity of 17 and a census of 2 residents at the time of the survey.

Findings include:

1. Observation on 06/01/2023 at 11:27 a.m., revealed a surge protector providing power to a microwave and toaster in the EVS Office of the basement. Maintenance Staff verified this observation at the time of the survey process.

2. Observation on 06/01/2023 at 11:29 a.m., revealed a surge protector providing power to a Keurig in the EVS Office of the basement. Maintenance Staff verified this observation at the time of the survey process.

3. Observation on 06/01/2023 at 11:37 a.m., revealed a surge protector providing power to a battery charger in the Maintenance Room of the Basement. The Maintenance Director confirmed the observation at the time of the survey.