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Based on interview and record review, the facility failed to protect the range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 11.2.1 by having them inspected and tested every six months. This deficient practice affected one of two smoke zones in the building, including the main dining room. This facility had a capacity of 22 and a census of 9 patients at the time of the survey.

Findings include:

Record review on 1/13/21 at 2:24 p.m., revealed the commercial cooking suppression system inspection documentation was not available at the time of the inspection.

This deficient practice was confirmed by Maintenance Staff at the time of exit.

Based on observation and record review, the facility failed to provide a properly tested and maintained fire alarm system. All the facility was directly affected by the deficient practice; all smoke compartments and approximately 49 residents and staff members. The facility has 22 certified beds and at the time of the survey the census was 9.

Findings include:

A review of the inspection records for the fire alarm system on 1/13/21 at 12:32 p.m., revealed the fire dampers have not been inspected within the last six years as required by code.

Administrative and Maintenance Staff verified this observation during the survey process.

Based on observation and record review, the facility failed to provide a properly tested and maintained fire alarm system. All the facility was directly affected by the deficient practice; all smoke compartments and approximately 49 residents and staff members. The facility has 22 certified beds and at the time of the survey the census was 9.

Findings include:

A review of the inspection records for the fire alarm system on 1/13/21 at 12:32 p.m., revealed the fire dampers have not been inspected within the last six years as required by code.
Administrative and Maintenance Staff verified this observation during the survey process.

Based on interview and record review, the facility did not assure that an adequate policy is in place regarding the procedures to be taken in the event that the fire alarm is out of service for more than four hours in any 24-hour period in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. Lack of written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. This deficient practice affected all occupants of the building in this facility with a capacity of 22 and a census of 9.

Findings include:

Interview with Maintenance Staff on 1/13/21 at 2:00 p.m., revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than four hours in a 24-hour period. The policy failed to include the following:

1.) The policy did not include the phone numbers of the contact list.
2.) The policy also lacked that the persons assigned to do fire watch would be dedicated. Record review of the facility layout showed this would affect all smoke zones.

Administrative Staff and Maintenance Staff confirmed the findings during the exit conference.

Based on interview and record review, this facility did not assure that a 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 affected all occupants of the building. This facility had a capacity of 22 and a census of 9 at the time of the survey.

Findings include:

Record review on 1/13/21 at 2:00 p.m., of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 10 hours in a 24-hour period. The policy failed to have the following information included in their policy as required by NFPA 25, 2011 Edition (Chapter 15):

15.2.1 The property owner or designated representative shall assign an impairment coordinator to comply with the requirements of this chapter.
15.2.2 In the absence of a specific designee, the property owner or designated representative shall be considered the impairment coordinator.
15.2.3 Where the lease, written use agreement, or management contract specifically grants the authority for inspection, testing, and maintenance of the fire protection system(s) to the tenant, management firm, or managing individual, the tenant, management firm, or managing individual shall assign a person as impairment coordinator.
15.3 Tag Impairment System.
15.3.1* A tag shall be used to indicate that a system, or part thereof, has been removed from service.
15.3.2* The tag shall be posted at each fire department connection and the system control valve, and other locations required by the authority having jurisdiction, indicating which system, or part thereof, has been removed from service.
15.4 Impaired Equipment.
15.4.1 The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service.
15.4.2 The impaired equipment shall include, but shall not be limited to, the following:
(1) Sprinkler systems
(2) Standpipe systems
(3) Fire hose systems
(4) Underground fire service mains
(5) Fire pumps
(6) Water storage tanks
(7) Water spray fixed systems
(8) Foam-water systems
(9) Fire service control valves

15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.

15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

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

15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.

15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

15.7 Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:

(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed.


Administrative Staff confirmed the findings during the exit conference.

Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6 for four of four quarters reviewed. The documentation did not show the drills have been held as required, including varying conditions (such as timing). The facility also did not conduct fire drills at least quarterly on each shift for three of four quarters. This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility had a capacity of 22 and a census of 9 residents at the time of the survey.

Findings include:

Record review on 1/13/21 at 11:23 a.m., of the facility fire drill documentation conducted during 2020 revealed the following: The third shift drills were held within the same hour 5:15 a.m., 5:21 a.m. and 6:15 a.m. and was missing a drill in the 3rd quarter. The first quarter was missing first and second shift drills. The third quarter was missing the second and third shift drills. The fourth quarter was missing the first quarter drill.
Results of the record review were acknowledged by Administrative Staff at the time of exit.

Based on record review and interview, this facility did not maintain the emergency generator by maintaining complete weekly and monthly documentation as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.1 or 8.3.4. The deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 22 and a census of 9 patients at the time of the survey.

Findings include:

Record review conducted on 1/13/21 at 12:05 p.m., of the facility's generator inspection testing and maintenance records from 2020 revealed:

1.) The documentation did not indicate the time to transfer during any of the monthly load tests, include a record of the meter readings, amperages, testing of nameplate rating, and run times.
2.) There was no documentation for the annual fuel quality test as required by code.

These deficient practices were confirmed by Maintenance Staff at the time of exit.

Based on record review and interview, this facility did not maintain the emergency generator by maintaining complete weekly and monthly documentation as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.1 or 8.3.4. The deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 22 and a census of 9 patients at the time of the survey.

Findings include:

Record review conducted on 1/13/21 at 12:05 p.m., of the facility's generator inspection testing and maintenance records from 2020 revealed:

1.) The documentation did not indicate the time to transfer during any of the monthly load tests, include a record of the meter readings, amperages, testing of nameplate rating, and run times.
2.) There was no documentation for the annual fuel quality test as required by code.

These deficient practices were confirmed by Maintenance Staff at the time of exit.