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Based on observations and interviews, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2. This deficient practice affects all staff within the Kitchen. The facility had a capacity of 25 patients and a census of 3 at the time of the survey.

Findings include:

Observation on 11/21/2024 at 12:02 p.m., revealed the Food Pantry Room within the Main Kitchen was not equipped with a self-closure device. This food pantry room measured approximately nine feet by twelve feet floor space.

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

Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2012 edition. This facility had an enclosed courtyard without a horn/strobe warning device. The deficient practice affects all occupants who may be in this area. This facility has a capacity of 25 with a census of 3 residents.

Findings include:

Observation and interview on 11/21/2024 at 11:38 a.m., revealed the enclosed Healing Garden Courtyard did not have an exterior horn/strobe device.

The Maintenance Director verified this observation at the time of this 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 25 and a census of 3 at the time of the survey.

Findings include:

1. Observation on 11/21/2024 at approximately 11:18 a.m., revealed the facility failed to maintain the sprinkler system near the Outpatient Surgery- Nurse's Station. The two sprinkler heads located near the desks area contained a large amount of accumulated dust.

2. Observation on 11/21/2024 at 12:04 p.m., revealed the facility failed to maintain the sprinkler system in the Kitchen. The sprinkler heads throughout this area contained an excessive amount of accumulated dust.

3. Observation on 11/21/2024 at 12:08 p.m., revealed the facility failed to maintain the sprinkler system in the Sprinkler Riser Room. The red metal box for stored extra sprinkler heads did not contain the required sprinkler head wrench.

4. Observation on 11/21/2024 at 10:00 a.m., revealed the facility failed to maintain the sprinkler system by not having documentation of quarterly inspections by Associated Fire Protection. A phone call to Associated Fire Protection indicated they had not conducted these inspections.

5. Observation on 11/21/2024 at 10:00 a.m., revealed the facility failed to maintain the sprinkler system by not have the required 5 year internal pipe inspection performed on time. The 12/13/2023 inspection paperwork from Associated Fire Protection mentioned in the note section that the fire year inspection was due.

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

Based on record review, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

Record review on 11/21/2024 at 10:20 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy was missing. The facility provided a sample policy from Lake Regional Healthcare, but they had not retyped this sample form for Myrtue Medical Center and incorporated the necessary information required in this policy including:

1) Extent and expected duration of the impairment have been determined.
2) The areas or buildings involved have been inspected and increased risks determined.
3) Recommendations have been submitted to management or the property owner.
4) Where the system is out of service for more than 10 hours in a 24 hour period, the impairment coordinator shall
arrange for one of the following:
a) Evaluation of the building or portion of the building affected by the outage.
b) An approved fire watch.
c) Establishment of a temporary water supply.
d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit
the amount of fuel available to a fire.
5) The fire department has been notified.
6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities
having jurisdiction have been notified.
7) The supervisors in the areas to be affected have been notified.
8) A tag impairment system has been implemented (See Section 15.3)
9) All necessary tools and materials have been assembled on the impairment site.

Sprinkler system outage policy addresses outages due to: system leakage, interruption of water supply, ruptured piping and equipment failure.

In addition, the sprinkler system outage policy must state contacting the following agencies at the beginning of implementing a fire watch and when the system is restored to normal:
-State Fire Marshal office and phone number
-Department of Inspections, Appeals and Licensing and phone number
-Insurance provider and phone number
-Local Fire Department and phone number.

Person performing the fire watch duties must perform the watch "continuously" and completed rounds at least every 30 minutes and be "dedicated" to the watch with no other responsibilities during this assignment.

The Maintenance Director verified the documentation at the time of the survey process.

Based on observation and interview, the facility failed to ensure the building's electrical system, wiring, and equipment are in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.1.2 and NFPA 70, National Electrical Code, 2011 edition, 110.26, by not providing or maintaining access and working space about electrical equipment. This deficient practice affects one of nine smoke zones. This facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

1. Observation on 11/21/2024 at 11:32 a.m., revealed a items stored in front of the electrical panels in the Electrical Closet adjacent to the Fire Alarm Panel Room.

2. Observation on 11/21/2024 at 11:58 a.m., revealed the faceplate on an electrical box for the water flow detection had been removed and not replaced on the box. This box was located outside the elevator D service room door.

3. Observation on 11/21/2024 at 11:24 a.m., revealed two electric clothes dryer vent tube sections were secured with gray duct tape. This duct tape needs to be removed and replaced with approved clothes dryer tape.

The Maintenance Director verified these observations during the survey.

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 3 residents at the time of the survey.

Findings include:

Record review on 11/21/2024, at 10:37 a.m. revealed the fire plan did not address the following information:

The plan did not address all the types of fire extinguishers located in this facility: (ABC, K-Type and the Ansul range hood suppression system) and the use of these extinguishers.

The 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 3 residents at the time of survey.

Findings include:

1. Record review and interview on 11/21/2024 at 9:44 a.m. of the facility's fire drill documentation, revealed the facility failed to sufficiently vary the time of fire drills during the first shift (7:00 a.m. - 7:00 p.m.) for the four quarters of 2024. The first shift, first quarter drill was conducted on 01/10/2024 at 7:10 a.m., the first shift, second quarter drill was conducted on 04/10/2024 at 8:00 a.m., the first shift, third quarter drill was conducted on 09/05/2024 at 9:00 a.m. and the first shift, fourth quarter drill was conducted on 10/30/2024 at 9:30 a.m.. In addition, the facility needs to ensure all staff members participating in the fire drills sign in on the rooster as being present for this training.

2. Record review and interview on 11/21/2024 at 9:44 a.m., revealed the overnight shift fire drill testing was not complete. During overnight shift drills, ensure the next day shift testing of the time of fire alarm, signal received and monitoring company information is documented on the previous overnight fire drill paperwork.

The Maintenance Director verified the documentation during the survey process.

Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms or where patient care may be provided as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects all residents, staff, and visitors in the affected areas. The facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 11/21/2024 at 10:20 a.m., revealed the facility provided documentation of hospital-grade receptacle testing upon installation, repairs or modifications for the electrical receptacles in patient rooms. The facility had not maintained or could provide documentation for hospital-grade receptacle testing for other areas of this facility where patient care may be provided.

The Maintenance Director confirmed this finding at the time of the survey.