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Based on observation and interview, the facility failed to maintain minimum construction requirements in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.6), 2012 Edition. This deficient practice affects approximately 5 residents, staff, and visitors in 1 of 2 smoke zones. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 10/02/23 at 12:51 p.m., revealed an approximate 5-inch by 5-inch hole in a 1-hour firewall. Located above the lay-in ceiling tile at the entrance to Radiology. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to test battery backup emergency lights in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.9.3.1.1(3)), 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 2.

Findings include:

Record review and interview on 10/02/23 at 10:34 a.m., revealed the facility was unable to provide current documentation for annual 90-minute functional testing of the battery backup emergency lights throughout the facility. Documentation provided indicates testing was last conducted June 8-9th, 2022. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.3), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 1 of 2 smoke zones. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 10/02/23 at 9:20 a.m., revealed the self-closing corridor door to the Materials Management Storage Room was being propped open with a wooden wedge. This room was greater than 50 square feet and being used for the storage of combustible materials. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide supervised smoke detection at the main fire alarm control panel in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-10.15), 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 2.
Findings include:
Observation and interview on 10/02/23 at 1:17 p.m., revealed the main fire alarm control panel was located in the Basement. The Basement is not continuously occupied and did not contain a supervised smoke detector as required. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to test their fire alarm system in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.4.5), 2010 Edition and National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-19.4.1.1 and Section 19.4.9), 2010 Edition. These deficient practices affect all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

1. Record review and interview on 10/02/23 at 10:14 a.m., revealed the facility is not testing their fire alarm system as required. Review of the annual fire alarm system test report from Midwest Alarms dated 04/21/23 revealed that all of the smoke detectors and pull stations throughout the building were listed as not tested. Review of the previous semi-annual fire alarm system test report from Midwest Alarms dated 11/11/22 revealed the devices were listed as to be tested in March of 2023 and they were not.

2. Record review and interview on 10/02/23 at 10:57 a.m., revealed the facility contained fire and smoke dampers in the duct work of their HVAC system. The facility was unable to provide documentation for inspection/testing of the dampers within the last 6 years. The Support Services Director and Maintenance Staff verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to conduct biennial sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.4.5.3.2), 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 2.

Findings include:

Record review and interview on 10/02/23 at 10:19 a.m., revealed the facility was past due for biennial sensitivity testing of the smoke detectors for the fire alarm system. Documentation provided indicates testing was last conducted on 04/22/21. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to install like sprinklers in accordance with National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems (Section-8.3.3.2), 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 2.

Findings include:

Observation and interview on 10/02/23 at 12:16 p.m., revealed the CT Addition corridor connected and open to the Med Surgery Hallway of the main building contained 2 quick response sprinklers installed while the remainder of the installed sprinklers in the same compartment were fusible link. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to supervise sprinkler valves in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.7.2.1), 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 2.

Findings include:

Observation and interview on 10/02/23 at 1:10 p.m., revealed the main water supply line for the sprinkler system coming into the building in the New Boiler Room contained 2 tamper valves. The valves were not wired in and interconnected to the fire alarm system so as to send a supervisory trouble signal should the valves happen to be in a closed position. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect their sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.1.1.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

Record review and interview on 10/02/23 at 10:11 a.m., revealed the facility was unable to provide documentation for quarterly inspection/testing of their sprinkler system for the 1st quarter of 2023. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure that corridor doors have a means of keeping the doors closed within the door frame in order to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.5), 2012 Edition. This deficient practice affects approximately 3 residents, staff, and visitors in 1 of 2 smoke zones. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 10/02/23 at 1:02 p.m., revealed the corridor door to the ER Utility Room failed to positively latch within the door frame in order to keep the door closed. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 2.

Findings include:

Record review and interview on 10/02/23 at 9:46 a.m., revealed the facility was unable to provide fire drill documentation for a 2nd shift drill for the 4th quarter of 2022. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect fire door assemblies in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-5.2.1), 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 2.

Findings include:

Record review and interview on 10/02/23 at 10:48 a.m., revealed the facility was unable to provide documentation for annual inspection and testing of the required fire rated door assemblies throughout the facility. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain, test, and inspect their emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.3.8, Section-8.4.1, Section-8.4.9, and Section-8.4.9.2), 2010 Edition. These deficient practices affect all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 2.

Findings include:

1. Record review and interview on 10/02/23 at 9:31 a.m., revealed the facility was past due for annual testing of fuel quality for their diesel powered emergency generator. Documentation provided indicates that annual testing was last completed on 04/14/22.

2. Record review and interview on 10/02/23 at 10:26 a.m., revealed the facility was unable to provide documentation for weekly inspections of their diesel powered emergency generator from 05/26/23 to the present.

3. Record review and interview on 10/02/23 at 10:38 a.m., revealed the facility was unable to provide documentation for a 4-hour continuous load test within the past 36 months for the facility's diesel powered emergency generator. The Support Services Director and Maintenance Staff verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that power strips are being used in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-10.2.3.6), 2012 Edition. This deficient practice affects approximately 4 residents, staff, and visitors in 1 of 2 smoke zones. This facility has a capacity of 25 and a census of 2.

Findings include:

Observation and interview on 10/02/23 at 9:20 a.m., revealed the Entrance #2 Waiting Area contained a surge protector being used to supply power to a mini-refrigerator. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility was unable to provide documentation that staff had been trained on handling of medical gases and cylinders in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-11.5.2.1), 2012 Edition. This deficient practice affects all staff that handle medical gases and cylinders. This facility has a capacity of 25 and a census of 2.
Findings include:
Record review and interview on 10/02/23 at 11:17 a.m., revealed the facility was unable to provide documentation that personnel who are concerned with the application and handling of medical gases and cylinders have been trained on their use. The Support Services Director and Maintenance Staff verified this observation at the time of the survey process.