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Based on record review and interview, the facility failed to inspect and maintain the automatic sprinkler system within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 14.2 and 5.2.1.1, by not ensuring an internal inspection of the piping was conducted within the last five years, by failing to address deficiencies noted on inspection documentation from the sprinkler system contractor, and by not ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. These deficient practices could affect all smoke compartments and occupants of the facility. The facility had a capacity of 25 and a census of 5 patients at the time of the survey.


Findings include:

1. Record review on 1/28/2025 between 11:01 a.m. and 11:53 a.m., of the facility's sprinkler system inspection reports, revealed the facility failed to maintain the fire sprinkler system by assuring the five year internal obstruction assessment had been conducted. Documentation showed the system had last been inspected for a five year internal testing in 2017 by Midwest Automatic Fire Sprinkler. Record review of the annual and quarterly sprinkler system reports provided to the facility by Midwest Automatic Fire sprinkler on 12/11/2024, 9/18/2024, 6/19/2024, 3/13/2024, 12/13/2023, 9/13/2023, 6/13/2023, 3/14/2023, 12/7/2022, 9/13/2022, 6/2/2022, and 3/8/2022 had a note that indicated the five year internal piping test was last performed in 2017, however, it had not been completed, making this testing approximately three years overdue.

Further record review of the documentation reports provided by Midwest Automatic Fire Sprinkler ranging from 12/11/2024 to 3/8/2022 showed a list of deficiencies that had been noted across these reports and no record of an invoice for corrective actions was available. The following is a list of deficiencies noted by the Midwest Automatic Fire Sprinkler contractor that appear to have not been addressed:

a. Needs outside bell above FDC.
b. Internal Inspection - 2017 - remodel.

A letter from Midwest Automatic Fire Sprinkler was provided to the facility along with every copy of their annual and quarterly inspections ranging from 12/11/2024 to 3/8/2022 which stated the following:

NFPA requires the following:
1. 5 year Internal Inspection of wet and dry systems (flushing of dry included).
2. 3 year dry system full trip test.
3. Replace air/water gauges every 5 years.
Sprinkler Testing:
"Fast response" at 20 years and every 10 years thereafter.
"Standard response" at 50 year and every 10 years thereafter.
Dry at 10 years and every 10 years thereafter.
Weekly/monthly run fire pump (if applicable)

"Midwest recommends the tests above, however, they are an extra expense and will be conducted ONLY at the owner's request".

Interview with the Maintenance Director revealed these deficiencies and letters had been on every report from the last three years. Some of the items recommenced from the sprinkler contractor are overdue such as the five year internal testing and the gauge replacement.

2. Observation on 1/28/2025 at 12:35 p.m., revealed the facility failed to maintain the sprinkler system in the Boiler Room. One sprinkler head contained an orange plastic cover over it.

The Maintenance Director and Administrator verified these findings during the survey and exit interview.

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 patients, staff, and visitors. The facility had a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

1. Record review on 1/28/2025 at 1:05 p.m., of the fire watch procedures for a sprinkler system outage in the facility's outage policy within the Emergency Preparedness binder did not list specifically what to do or any of the specific verbiage for the sprinkler outage policy. The policy was incomplete in that it did not address and was missing the following information:

1. Extent and expected duration of the impairment have been determined.

2. The areas of buildings involved have been inspected and increased risks determined.

3. Recommendations have been submitted to management or the property owner.

4. All preplanned impairments shall be authorized by the impairment coordinator, who shall verify the following procedures have been implemented:

(1) Evacuation of the building or portion of the building affected by the outage.
(2) Establishment of a temporary water supply.
(3) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire.

5. The insurance carrier, the alarm company, property owner or designated representative, and other Authorities having jurisdiction have been notified.

6. The supervisors in the areas to be affected have been notified.

7. A tag impairment system has been implemented.

8. All necessary tools and materials have been assembled on the impairment site.

2. The policy also did not contain exact verbiage addressing the following: System leakage, interruption of water supply, ruptured piping, and equipment failure.

3. The policy also did not contain the contact phone number for the facility's insurance company.

The Maintenance Director and Administrative Staff verified the documentation at the time of the survey.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 25 and a census of 5 patients at the time of survey.

Findings include:

1. Record review and interview on 1/28/2025 between 10:47 a.m. and 10:58 a.m., of the facility's fire drill documentation, revealed the facility runs two 12-hour shifts, however, they failed to conduct a fire drill during the second shift for the second quarter and during the first shift for the third quarter of 2024. During the second quarter of 2024 only one drill was ran on 5/25/2024 at 4:30 p.m.. During the third quarter of 2024 only one drill was ran on 7/10/2024 at 9:15 p.m..

2. Record review and interview on 1/28/2025 between 10:47 a.m. and 10:58 a.m., of the facility's fire drill documentation, revealed second shift drills were conducted at approximately the same time of day. Four second shift drills were conducted between 8:50 p.m. and 9:54 p.m.: on 7/10/2024 at 9:15 p.m., on 10/9/2024 at 8:50 p.m., on 12/29/2024 at 9:54 p.m., and on 1/22/2025 at 8:51 p.m..

The Maintenance Director verified the documentation during the survey.

Based on record review and interview, the facility failed to maintain complete documentation of the inspections, exercising, and operation of the emergency generator power supply and to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4 and 8.3.8 respectively, by not ensuring a monthly load test was completed per the requirements This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

Record review on 1/28/2025 between 10:21 a.m. and 11:05 a.m., revealed the facility failed to maintain proper documentation of monthly exercising under load for the facility's diesel generator. The facility had only documented the load percentage each month on their weekly generator testing forms once a month, however, they were missing the following information for their monthly load tests:

a. Meter Readings
b. Transfer Switch Operated
c. Amperages Recorded (Each Leg)
d. Meter Start & Stop Times Recorded

Each of these items should be documented along with the load percentages each month during their monthly load testing.


The Maintenance Director confirmed the documentation during the survey.