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Based on record review and interview, the facility failed to test the 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 4.

Findings include:

Record review and interview on 01/30/25 at 11:06 a.m., revealed the facility was unable to provide current documentation for Annual 90-Minute Functional Testing for the battery backup emergency lights. The Maintenance Supervisor and Support Services Manager verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-14.2.1) & (Section-13.4.4.2.2.2), 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 4.

Findings include:

1. Record review and interview on 01/30/25 at 10:35 a.m., revealed the facility failed to have a 5-year internal obstruction inspection performed for the automatic sprinkler system. The last documented 5-year internal obstruction inspection from the facility ' s sprinkler contractor was dated 01/11/17. Interview with the Maintenance Supervisor indicated that the test had not been completed. The Maintenance Supervisor and Support Services Manager verified this observation at the time of the survey process.


2. Record review and interview on 01/30/25 at 10:53 a.m., revealed the dry pipe sprinkler valve was past due for a 3-year full trip of the system. The last 3-year full trip was conducted in August of 2017. Interview with the Maintenance Supervisor indicated that the test had not been completed. The Maintenance Supervisor and Support Services Manager verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect and exercise main and feeder circuit breakers for their emergency generator in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.4.4.1.2.1), 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 4.
Findings include:
Record review and interview on 01/30/25 at 11:25 a.m., revealed that the facility was unable to provide documentation for annual inspection and exercising of the main and feeder circuit breakers for their emergency generator. The Maintenance Supervisor and Support Services Manager verified this observation at the time of the survey process.