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Based on observation and interview, the facility failed to maintain smoke detection in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-17.7.4.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Observation and interview on 04/17/25 at 9:44 a.m., revealed a smoke detector located in the Main Entrance Lobby was within 36 inches of an air supply. The smoke detector will need to be moved at least 36 inches away from any air supply.

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

Based on observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems Section-5.2.1.1.1, 2011 Edition. This deficient practice affect all residents, staff, and visitors in the kitchen. This facility has a capacity of 25 and a census of 4.

Findings include:

Observation and interview on 04/17/25 at 12:02 p.m., revealed the Kitchen had multiple quick response sprinklers covered in lint and dust and required cleaning.

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

Based on record review and interview, the facility failed to provide a complete fire safety plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.2.2(9)), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 04/17/25 at 11:46 a.m., revealed the provided Fire Safety Plan did not address the use of the different types of portable fire extinguishers in the facility. Nor did the plan address the use of the Ansul extinguishment system for the kitchen hood.

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

Based on record review and interview, the facility was not properly documenting all elements of testing for the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.4.2), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 04/17/25 at 9:55 a.m., revealed that during monthly load testing of the facility's diesel powered Emergency Generator the facility failed to record meter start and stop time from 1/24/24 - 7/22/24, 1/16/25 & 3/3/25. The facility also failed to record the amperage for each leg of the testing.

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

Based on observation and interview, the facility is not assuring that extension cords are being used in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-10.2.4), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electric Code (Section-400.8), 2011 Edition. This deficient practice affects all staff and residents throughout the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Observation and interview on 04/17/25 at 11:57 a.m., revealed on the first floor in the Corner Mechanical Room there was an extension cord providing power to a standing fan.

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