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Based upon a review of records and staff interview, this facility is not assuring that a complete policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period. 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 residents, patients, visitors and staff in 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 21 at the time of this survey.

Findings include:

During the tour conducted on 05/11/2017, between 1:30 p.m. and 3:30 p.m., a review of record revealed that the facility does not have a policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period.

Maintenance Director was present and affirmed results of the records review.

NFPA Standard: Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

NFPA Standard: Complete records of all signals received shall be retained for at least 1 year. Testing and maintenance records shall be retained as required by 14.6.3. The central station shall make arrangements to furnish reports of signals received to the authority having jurisdiction in a manner approved by the authority having jurisdiction. Testing and maintenance for central station service shall be performed in accordance with Chapter 14. 2010 NFPA 72

Based on record review, observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25 by not providing complete documentation of monthly visual inspections of the automatic, wet-pipe sprinkler system. This deficient practice could compromise the effectiveness of the fire suppression system, affecting all residents, patients, visitors and staff in 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 21 at the time of this survey.

Findings include:

During the tour conducted on 05/11/17, between 1:30 p.m. and 3:30 p.m., during a review of records, it is observed:

-- 1. No documented monthly visual inspections of the automatic fire sprinkler system prior to September 2016 and after December 2016 through the date of this survey.

Maintenance Director was present and acknowledged the results of the records review.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5.

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1

Based on interview and record review, this facility is not assuring 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 ten hours in any twenty-four hour period. 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 would affect all occupants of the building, including patients, residents, visitors and staff in 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 21 at the time of this survey.

Findings include:

During the tour conducted on 05/11/17, between 1:30 p.m. 4:30 p.m., a review of records revealed that the facility does not have a policy in place regarding the procedures to be taken in the event that the fire sprinkler is out of service for more than ten hours in any twenty-four hour period.

Maintenance Director was present and acknowledged the findings.

NFPA Standard: Where the inspection, testing, and maintenance of standpipe and hose systems results or involves a system that is out of service, the impairment procedures outlined in Chapter 15 shall be followed. 2011 NFPA 25 6.1.6

NFPA Standard: The following procedures shall implemented: the extent and expected duration of the impairment shall be determined; the areas or buildings involved have been inspected and the increased risks determined; recommendations submitted to management or the property owner or designated representative. 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: evacuation of the building or portion of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire; the fire department has been notified; the insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified; the supervisors in the areas to be affected have been notified; tag impairment system has been implemented. (See Section 15.3.); all necessary tools and materials have been assembled on the impairment site. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2011 NFPA 25, 15.5.2

Based upon observation and staff interview, the facility fails to assure that Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10. The deficient practice does not ensure that fire extinguishers are ready and may be relied upon to extinguish a fire, affecting all residents and any visitors or staff in 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 21 at the time of this survey.

Findings include:

During the tour conducted on 05/11/17 & 05/12/17, a review of annual service tags on portable fire extinguishers revealed no monthly visual inspections for the months of July and August 2016.

Maintenance Director was present and acknowledged the findings.

NFPA Standard: Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers 18.3.5.12, 19.3.5.12, NFPA 10

NFPA Standard: Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals per 2010 NFPA 10, 7.2.1.2

Based upon record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents, visitors and staff in 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 21 at the time of this survey.

Findings include:

During the tour conducted on 05/11/2017, between 1:30 p.m. and 3:30 p.m., a review of fire drill records for the last 4 quarters revealed the following:

-- 1. No documented drill for the 1st Shift, 2nd Qtr. 2016; 1st, 2nd, and 3rd Shift, 3rd Qtr. 2016; 2nd Shift, 1st Qtr. 2017.

-- 2. Documented drills for the 3rd Shift, 4th Qtr. 2016, and 1st and 2nd Qtr. 2017 do not include scenarios. The documentation does not contain enough information to assure that actual actions were taken to simulate the conditions of an actual fire.

Maintenance Director was present and acknowledged the results of the record review.

NFPA Standard: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff (nurses, interns, maintenance engineers, and administrative staff) is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7