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Based on observation, interview and record review, the facility failed to protect resident rooms in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18/19.3.2.5.4. The facility was allowing the use of unapproved kitchen appliances (microwaves) within two of twelve smoke zones. The facility had a capacity of 99 and a census of 28 at the time of the survey.

Findings Include:

Observation on 3/09/2022 between the times of 11:05 a.m. and 12:00 p.m., revealed the following patient care resident rooms within the OB Wing and the Skilled Nursing Hall contained unapproved kitchen appliances (Microwaves). Resident Rooms 362, 363, 364, 366, 368, 369, 370, and 371 all contained a microwave installed within the entertainment center.

The Maintenance Director verified these findings at the time of the survey.

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. The facility had a capacity of 99 and a census of 28 at the time of the survey.

Findings include:

1. Observation on 03/09/2022 at 10:49 a.m., revealed the sprinkler head located within the OB Storage Room appeared to be bent and at an angle that could cause the spray pattern to be ineffective.

2. Observation on 03/09/2022 at 11:19 a.m., revealed the sprinkler head located within the Elevator Shaft Room on the 1st Floor contained lint and dust throughout.

The Maintenance Director verified these findings at the time of the 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 affected two of twelve smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 99 and a census of 28 residents at the time of the survey.

Findings include:

1. Observation on 03/09/2022 at 11:22 a.m., revealed a rubber door wedge holding open the PEDS Storage Room door. At the time of the survey, this corridor door was installed with a self-closing device and was currently being used as an office.

2. Observation on 03/09/2022 at 11:40 a.m., revealed a rubber door wedge holding open the Wolfe Eye Clinic Breakroom door on the second floor. This door was installed with a self-closing device.

The Maintenance Director verified these findings 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 99 and a census of 28 residents at the time of survey.

Findings include:

Record review on 03/09/2022 at 9:46 a.m., of the facility's fire drill documentation, revealed the facility failed to consistently conduct required fire drills throughout 2021/2022. Further record review of facility fire drill documentation revealed the most recent fire drills on file for the day shift were conducted in 2019/2020, with one drill conducted on 2/6/2021 at 1:25 p.m. Record review of the evening and night shift fire drills revealed the first, second, third, and fourth
quarter drills were last conducted/documented in 2019/2020.

The Maintenance Director verified these findings at the time of the survey.

Based on record review and interview, the facility failed to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 99 and a census of 28 residents at the time of the survey.

Findings include:

1. Record review on 03/09/2022 at 9:37 a.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator diesel fuel.

2. Record review on 03/09/2022 at 10:15 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. Interview of facility staff revealed that the facility was unsure if the annual test had been conducted or where the documentation would be located. The current Maintenance Director was aware of this requirement, but had just recently replaced the previous Maintenance Director.

The Maintenance Director and the Administrator confirmed these findings at the time of the survey.