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Based on record review and staff interview, the facility failed to inspect and service the Kitchen Hood and Duct Extinguishment System in accordance with National Fire Protection Association, NFPA 96, 2011 edition. The system shall be inspected twice a year at an interval of 6 months. Cleaning shall be provided throughout the entire exhaust/ventilation system. The deficient practice affects the entire facility The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 5/17/23 at 9:50 a.m., revealed the following deficiencies:

1. Available documentation revealed the last inspections of the Kitchen Hood and Duct Extinguishment System were dated 9/14/22 and 9/14/22. The interval between the two inspections was in excess of 6 months.
2. There was no available documentation indicating the Kitchen Hood and Duct Extinguishment System has been cleaned throughout the entire exhaust/ventilation system as required. Maintenance Staff indicated the Kitchen Staff only cleans the filters and the visible system components directly above the cooking equipment. Maintenance Staff indicated they were not aware of the requirement of cleaning the entire exhaust/ventilation system.

Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to inspect and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. Smoke detectors shall be tested for sensitivity every 2 years. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 5/17/23 at 12:25 p.m., revealed no available documentation of smoke detector sensitivity testing within the past 2 years as required. Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 5/17/23 at 1:53 p.m., revealed the following deficiencies:

1. There was a dirty sprinkler head on the ceiling of the Kitchen by the Kitchen Hood and Duct Extinguishment System.
2. There was a dirty sprinkler head on the ceiling of the Kitchen near the pull station for the Kitchen Hood and Duct Extinguishment System.
3. There was a dirty sprinkler head on the ceiling of the Cafeteria by the Corridor Entrance Door.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the building's electrical system in accordance with National Fire Protection Association, NFPA 70, 2010 Edition. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observation and staff interview on 5/17/23 at 1:39 p.m., revealed an open electrical junction box on the ceiling of the Boiler Room, above the medical gas system pump. Maintenance Staff verified observations during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills quarterly on each shift for three of four quarters reviewed in accordance with 2012 Life Safety Code, 19.7. 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 has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 5/17/23 at 12:18 p.m., revealed the following deficiencies:

1. There was no available documentation of a fire drill conducted on the 1st Shift in the 2nd Quarter of 2022.
2. There was no available documentation of a fire drill conducted on the 2nd Shift in the 3rd Quarter of 2022.
3. There was no available documentation of a fire drill conducted on the 3rd Shift in the 4th Quarter of 2022.

Maintenance Staff verified record review during the survey process.

Based upon record review and staff interview, the facility failed to provide documentation indicating that applicable staff are provided with oxygen safety training as required by National Fire Protection Association, NFPA 99, 2012 Edition, 11.5.2.1. The deficient practice affects the entire facility. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 5/17/23 at 1:27 p.m., revealed no available documentation of oxygen safety training for applicable staff as required. Administrative Staff verified record review for this deficiency during the survey process.