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Based on surveyor observation and staff interview, the facility failed to maintain the Type II (111) construction type of the building in accordance with National Fire Protection Association (NFPA) 101, section 18.1.6.1. This deficient practice affects staff members in 1 of 13 zones. The facility has a capacity of 68 and a census of 5.

Findings include:

Observations and interview on 03/22/22 at 11:43 a.m., revealed a structural steel beam on the ceiling of the Operating Room Air Handling Room that was missing an approximately 4-inch by 18-inch section of fire protection coating.

Administrative Staff A observed this finding.

Based on observation and interview, the facility did not maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 edition.. This deficient practice affects all occupants in 13 of 13 zones. This facility had a capacity of 68 and a census of 5 patients at the time of the survey.

Findings include:

Observation and interview on 03/22/22 at 9:30 a.m., revealed the most recent fire alarm system inspection report was dated 03/01/21. The fire alarm system shall be serviced semi-annually.

Administrative Staff A observed this finding.

Based on record review and staff interview, the facility failed to provide a Fire Safety Plan in accordance with National Fire Protection Association (NFPA) 101, 2012 edition, section 19.7.2.2. This deficient practice affects 5 patients in 13 of 13 zones. The facility has a capacity of 68 and a census of 5.

Findings include:

Record review and interview on 03/22/22 at 9:55 a.m., revealed the facility's Fire Safety Plan failed to address the following information:

a. Use of the hood & duct extinguishment system in the Kitchen.
b. Use of the different types of fire extinguishers.
c. The preparation of the floors and building for evacuation.
d. Written evacuation plans from each smoke zone in the building.

Administrative Staff A observed this finding.

Based on record review and interview, this facility did not maintain the emergency generator by maintaining complete monthly documentation as required by National Fire Protection Association (NFPA) 99, 6.4.4, 6.5.4, & 6.6.4. The deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator did not ensure proper operation and prompt repair affecting all occupants. This deficient practice affects 5 patients in 13 of 13 zones. This facility had a capacity of 68 and a census of 5 residents at the time of the survey.

Findings include:

Record review and interview on 03/22/22 at 10:38 a.m. revealed the following deficiencies:

1. The monthly generator run log failed to indicate the percentage of nameplate the generator was running at during the tests.
2. The monthly generator run log failed to indicate the generator test stop times.

Administrative Staff A observed these findings.