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Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all staff who may be in the Kitchen. The facility had a capacity of 25 and a census of 5 at the time of the survey.

Findings include:

Observation on 05/10/2023 at approximately 11:14 a.m., revealed the facility failed to maintain the sprinkler system in the Kitchen. Two of eight sprinkler heads contained lint and grease build up.

Maintenance Staff confirmed this finding during the survey.

Based on observation and interview, the facility failed to install portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 2010 edition, 6.1.3.4, by ensuring all portable, non-wheeled fire extinguishers are installed on a hanger, in a supplied or listed bracket, or in cabinets or wall recesses. This deficient practice affects two fire extinguishers in two of four smoke compartments and could affect staff in the Boiler Room and Mechanical Room 2. This facility had a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

1. Observation on 05/10/2023 at 10:00 a.m., revealed the fire extinguisher in the Lower Level Boiler Room was sitting on the floor. Interview of Maintenance Staff revealed that he has been unable to locate a device to hang this extinguisher.

2. Observation on 05/10/2023 at 10:35 a.m. revealed the fire extinguisher in the Old 1st Floor Mechanical Room 2 was sitting on the floor. Interview of Maintenance Staff revealed that he has been unable to locate a device to hang this extinguisher.

Maintenance Staff verified these observations during the survey process.

Based on observation, record review and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments, are smoke resisting and are positive latching as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3. This deficient practice affected all occupants in one of four smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

1. Observation on 05/10/2023, at 10:23 a.m., revealed a door inside the Old PT Entrance to be held open by a door wedge. This door is at the top of the stairs.

2. Observation on 05/10/2023, at 11:00 a.m., revealed a door in the Kitchen Hallway was being held open by a yellow door wedge. Maintenance Staff removed this wedge during the survey.

Maintenance Staff confirmed the findings at the times of discovery.

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, 314.25, by not ensuring each box in completed installations shall have a cover. This deficient practice affects staff in one of four smoke zones. The facility has a capacity of 25 and a census of 5.

Findings Include:

Observation on 05/10/2023 at 11:25 a.m., revealed the facility failed to maintain the electrical system in the Boiler Room near the PT area. This room contained an open junction box with exposed electrical wiring on the back of a heater.

Maintenance Staff confirmed this observation during the survey.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four 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 25 and a census of 5 patients at the time of survey.

Findings include:

1. Record review on 05/10/2023 at 08:50 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct a fire drill during the first shift for the second quarter of 2022/2023.

2. Record review on 05/10/2023 at 08:50 a.m. of the facility's fire drill documentation, revealed first and second shift drills were conducted at approximately the same time of day. Two first shift drills were conducted between 01:31 p.m. and 02:05 p.m.: on 07/11/2022 at 01:31 p.m. and 11/09/2022 at 02:05 p.m. Two second shift drills were conducted between 09:30 p.m. and 10:00 p.m.: on 04/20/2023 at 09:30 p.m. and 02/13/2023 at 10:00 p.m.

Maintenance Staff verified the documentation during the survey process.