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Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.6.1.3 and NFPA Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 10.5.5.3 by ensuring the fire alarm dedicated branch circuit(s) be mechanically protected. This deficient practice affects all occupants of the building, including clients, staff, and visitors. This facility has a capacity of 25 with a census of 9.

Findings include:

Observation on 11/15/2022 at 10:00 a.m., revealed the fire alarm breaker, located in electrical panel Circuit #7 in the Mechanical Room was not secured with a mechanical lock.

The building staff verified this observation during the survey.

Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.6.1.3 and NFPA Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 10.5.5.3 by ensuring the fire alarm dedicated branch circuit(s) be mechanically protected. This deficient practice affects all occupants of the building, including clients, staff, and visitors. This facility has a capacity of 25 with a census of 9.

Findings include:

Observation on 11/15/2022 at 10:58 a.m., revealed the fire alarm breaker, located in electrical Panel LSL Circuit #1 in Room #299, was not secured with a mechanical lock.

The Director of Maintenance verified this observation during the survey.

Based on record review and interview, the facility failed to conduct the required biennial sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 14.4.5.3.2. This deficient practice affects all occupants as this lack of testing would not ensure the sensitivity of the detectors was within the manufacturer's specification. The facility had a capacity of 25 and a census of 9 residents at the time of the survey.

Findings include:

Record review and interview on 11/15/2022 at 11:57 a.m. of the facility's fire alarm system inspection documentation, revealed the facility was unable to produce documentation that the sensitivity of the smoke detectors had been tested within the previous two years. The Maintenance Director called the fire alarm company, 3D Security Inc., who had been performing the fire system inspections for this facility for the last twenty years. Their records indicated they have never performed a sensitivity test at this facility. The Maintenance Director scheduled 3D Security Inc. to conduct this testing within the next month.

The Maintenance Director verified the documentation during the survey process.

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 Laundry Room. The facility had a capacity of 25 and a census of 9 at the time of the survey.

Findings include:

Observation and interview on 11/15/2022 at approximately 10:10 a.m., revealed the facility failed to maintain the sprinkler system in the Laundry Room. Sprinkler heads contained lint and dust throughout.

The Maintenance Supervisor verified this observation 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 was observed on multiple occasions throughout this facility not allowing doors to prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 9 residents at the time of the survey.

Findings include:

Observation on 11/15/2022, between 9:50 a.m. and 10:10 a.m., revealed multiple instances where door wedges were observed throughout this facility. These door wedges were preventing the closing of doors on closure and would contribute to the spread of fire and smoke.

The Building Staff confirmed these observations at the time of this survey.

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 was observed on multiple occasions throughout this facility not allowing doors to prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 9 residents at the time of the survey.

Findings include:

Observation on 6/22/18, between 9:40 a.m. and 11:43 a.m., revealed multiple instances where door wedges were observed throughout this facility. These door wedges were preventing the closing of doors on closure and would contribute to the spread of fire and smoke.

The Maintenance Director confired these observations at the time of this survey.

Based on observation and interview, the facility is not assuring that 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 residents, staff, and visitors in one of six smoke zones. The facility has a capacity of 25 with a census of 9.

Findings include:

Observations and interview on 11/15/2022 at 10:30 a.m., revealed the north brick wall in the Phone Room contained an approximately 2 inch by 2 inch hole where a shelf was removed.

The Maintenance Supervisor verified this observation during the survey process.

Based on observation and interview, the facility failed to provide heating devices that are designed and installed so that combustible material cannot be ignited by the device or its appurtenances according to National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.5.2.2, by using duct tape to seal vent piping sections for one of the clothing dryers in the Main Laundry Room. This deficient practice affect staff of the facility. The facility had a capacity of 25 and a census of 9 at the time of the survey.

Findings include:

Observation and interview on 11/15/2022 at 10:15 a.m., revealed unapproved duct tape was used to seal the connections between sections of clothes dryer vent tubing in the Laundry Room.

The Maintenance Director confirmed this observation at the time of discovery.

Based on interview and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1/19.7.1 and 18.7.2/19.7.2. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 25 and a census of 9 in patients at the time of the survey.

Findings include:

Record review on 11/15/2022, at 12:09 p.m. revealed the fire plan did not address the following information:

The plan did not address all the types of fire extinguishers and how to use them or information about the range hood suppression system.

The Plant Operations Director and Maintenance Director verified this finding at the time of 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 9 residents at the time of survey.

Findings include:

Record review and interview on 11/15/2022 at 12:33 p.m. of the facility's fire drill documentation, revealed second shift (6 p.m.-6 a.m.) drills were conducted at approximately the same time of day. The first quarter 2022 second shift drill was conducted on 01/26/2022 at 6:35 p.m.; the second quarter drill was conducted on 04/14/2022 at 6:00 p.m.; the third quarter drill was conducted on 09/29/2022 at 6:04 p.m. and the fourth quarter 2021 second shift drill was conducted on 11/15/2021 at 6:30 p.m.

The Maintenance Director verified the documentation during the survey process.

Based on record review and interview, this facility is not providing proper documentation of inspection and testing of fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This facility had a capacity of 25 and a census of 9 in patients at the time of the survey.

Findings include:

Record review on 11/15/2022 at 11:58 a.m., revealed the facility could not provide full documentation of annual inspection and testing of fire and/or smoke door assemblies within the facility. Interview of Maintenance Staff revealed the facility had not conducted annual fire door inspections in the last five years.

The Plant Operations Director and Maintenance Director confirmed the documentation at the time of the survey.

Based on observation and interview, the facility did not prohibit the use of extension cords beyond temporary installation or as a substitute for adequate wiring in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition and NFPA 70, National Electrical Code, 2011 edition. This deficient practice may create electrical injury and fire hazards affecting staff in the Basement of the facility. This facility had a capacity of 25 and a census of 9 in patients at the time of the survey.

Findings include:

Observation on 11/15/2022 at 10:05 a.m., revealed an extension cord providing power to a space heater and sound machine in the Physician Office.

The Building Staff confirmed this observation at the time of this 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 all residents, visitors and staff in the affected areas. The facility had a capacity of 25 and a census of 9 residents at the time of the survey.

Findings include:

1. Observation and interview on 11/15/2022 at 9:25 a.m., revealed a surge protector providing power to a fan on the desk of covid screening area in the Main Entrance Lobby.

2. Observation and interview on 11/15/2022 at 9:28 a.m., revealed a surge protector providing power to a fan in the Billing Office.

3. Observation and interview on 11/15/2022 at 9:32 a.m., revealed a surge protector providing power to a mini-refrigerator, microwave oven, toaster and Keurig coffee maker in the Business Office.

4. Observation and interview on 11/15/2022 at 10:50 a.m., revealed a surge protector providing power to a mini-refrigerator, microwave oven and Keurig coffee maker in the Staff Locker Lab.

The Maintenance Director confirmed these observations at the time of the survey.