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Based on record review and interview, the facility failed to inspect, test, 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. This deficient practice could affect all occupants within the facility. The facility had a capacity of 11 patients and a census of 2.

Findings include:

Record review on 05/17/2023 at 11:05 a.m., revealed the facility was not able to provide documentation of quarterly sprinkler system inspections for the first, third, and fourth quarter of 2022/2023. One record of an annual inspection completed by Howe was provided showing an inspection date of 06/10/2022. The tag on the sprinkler riser also showed that the the last inspection was completed on 06/10/2022.

Maintenance Staff verified this finding during the survey process.

Based on record review and interview, 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 residents, staff, and visitors. The facility had a capacity of 11 and a census of 2 patients at the time of the survey.

Findings include:

Record review on 05/17/2023 at 11:55 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy did not instruct facility personnel to contact the insurance carrier (with contact information) at the beginning and conclusion of the fire watch. The policy also was incomplete in that it did not define emergency impairments to include system leakage, interruption of water supply, ruptured piping, and equipment failure.

Maintenance Staff verified the documentation during the survey process.

Based on record review and interview, the facility could not provide documentation of portable fire extinguisher inspections in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.7.4.1 and NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, 7.2.1.2 and 7.2.4.1. This deficient practice affects one fire extinguisher in the facility and patients and staff in the Pre Surgery Hall. This facility had a capacity of 11 and a census of 2 patients at the time of the survey.

Findings include:

Observation on 05/17/2023 at 10:00 a.m., revealed the facility missed monthly inspections of one portable fire extinguisher from 10/2022 - 1/2023. This portable fire extinguisher was located in the Pre Surgery Hall by the Anesthesia Room.

Maintenance Staff confirmed this finding at the time of discovery.

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 three of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility had a capacity of 11 and a census of 2 patients at the time of survey.

Findings include:

1. Record review on 05/17/2023 at 9:20 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct fire drills during the second shift for the first, third, and fourth quarter of 2022/2023.

2. Record review on 05/17/2023 at 9:20 a.m. of the facility's fire drill documentation, revealed first shift drills were conducted at approximately the same time of day. Three first shift drills were conducted between 9:56 a.m. and 10:15 a.m.: on 10/28/2022 at 9:56 a.m., 09/30/2022 at 10:05 a.m., and 03/30/2023 at 10:15 a.m.

Maintenance Staff verified the documentation during the survey process.

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 documenting fuel level, oil level, and belts/hoses on the weekly inspections of the diesel generator. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 11 and a census of 2 residents at the time of the survey.

Findings include:

Record review on 05/17/2023 at 8:55 a.m., revealed the facility failed to maintain proper documentation of weekly inspections for the facility's diesel generator. The facility did not document fuel level, oil level, and belt/hoses checks during weekly inspections.

Maintenance Staff verified the documentation during the survey.