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Based on observation and interview, 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, 19.3.2.1.3. This deficient practice affects one of eight smoke zones and could affect residents, staff, and visitors within the affected zone. The facility had a capacity of 25 residents and a census of 12.

Findings include:

Observation and interview on 9/23/2020 at 11:43 a.m., revealed the Pantry in the Kitchen exceeded 50 square feet in size and did not contain a self-closure device on the door. This room contained storage of canned as well as dry goods.

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

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 12 residents at the time of the survey.

Findings include:

Record review on 9/23/2020, at 10:49 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy was incomplete in that it did not address and was missing the following information:

1. Tagging an impaired system that has been removed from service at each fire department connection and the system control valve indicating which system, or part thereof, has been removed from service.

2. Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

The Maintenance Director verified the documentation 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 did not affect any occupants, but could affect approximately 12 staff members in one of eight smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 12 residents at the time of the survey.

Findings include:

Observation on 9/23/2020, at 1:18 p.m., revealed the Lab Storage Room door was being held open with a weighted card board box. This door was a rated door and is installed with an automatic door closure.

The Maintenance Director confirmed this finding 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 Laboratory Room. This facility had a capacity of 25 and a census of 12 residents at the time of the survey.

Findings include:

Observation on 9/23/2020 at 12:18 p.m., revealed a microwave within the Laboratory Storage Room was plugged into a yellow extension cord which was plugged into an electrical receptacle in the wall.

This deficient practice was confirmed by the Maintenance Director at the time of the survey.