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Based on observation and interview, the facility failed to maintain minimum construction requirements in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.6), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 3 of 5 smoke zones. This facility has a capacity of 18 and a census of 2.

Findings include:

1. Observation and interview on 10/18/22 at 12:44 p.m., revealed the labeled 1-hour fire rated wall in the IT Room contained several open to the center conduit penetrations.

2. Observation and interview on 10/18/22 at 12:57 p.m., revealed a labeled 1-hour fire rated wall that contained several open to the center conduit penetrations. Located above ceiling at the entry to Med Surgery. The Director of Facilities verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide unobstructed egress in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.2.1.5.3), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 3 of 5 smoke zones. This facility has a capacity of 18 and a census of 2.

Findings include:

1. Observation and interview on 10/18/22 at 12:37 p.m., revealed the corridor door to the Admin Work Room contained a dead bolt type lock. This lock mechanism would require a two motion twisting manipulation in order to egress from the room should the dead bolt happen to be locked.

2. Observation and interview on 10/18/22 at 1:10 p.m., revealed that both the north and south egress doors from the PT Work Room/Office contained dead bolt type locks. These lock mechanisms would require a two motion twisting manipulation in order to egress from the room should the dead bolts happen to be locked.

3. Observation and interview on 10/18/22 at 1:22 p.m., revealed the corridor door to the Echocardiology Room contained a dead bolt type lock. This lock mechanism would require a two motion twisting manipulation in order to egress from the room should the dead bolt happen to be locked.

4. Observation and interview on 10/18/22 at 1:24 p.m., revealed the corridor door to the Ultrasound Room contained a dead bolt type lock. This lock mechanism would require a two motion twisting manipulation in order to egress from the room should the dead bolt happen to be locked. The Director of Facilities verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to ensure that required self-closing/latching doors are maintained in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.2.2.2.7), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 2 of 5 smoke zones. This facility has a capacity of 18 and a census of 2.

Findings include:

Observation and interview on 10/18/22 at 12:52 p.m., revealed the 60-minute fire rated cross corridor double doors at the entry to Med Surgery failed to positively latch within the door frame in order to keep the doors closed. The Director of Facilities verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.3), 2012 Edition. This deficient practice affects approximately 4 residents, staff, and visitors in 1 of 5 smoke zones. This facility has a capacity of 18 and a census of 2.

Findings include:

Observation and interview on 10/18/22 at 12:30 p.m., revealed the self-closing 60-minute fire rated door to the Clean Utility Storage Room was being held open with a wedge. The Director of Facilities verified this observation and removed the wedge at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems (Section-6.2.7.2), 2010 Edition and National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.2.2.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 18 and a census of 2.
Findings include:
1. Observation and interview on 10/18/22 at 12:09 p.m., revealed the escutcheon for the quick response sprinkler in the Mail Room was missing.
2. Observation and interview on 10/18/22 at 12:44 p.m., revealed black communications wires zip tied to the sprinkler piping in the IT Room. The Director of Facilities verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to provide an adequate outage policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.5.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 18 and a census of 2.

Findings include:

Record review and interview on 10/18/22 at 11:00 a.m., revealed the provided Sprinkler Outage Policy for the system being out of service for 10 or more hours in a 24 hour period did not include contact information for the facility's insurance carrier. The Director of Facilities verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure that corridor doors have a means of keeping the doors closed within the doorframe in order to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.5), 2012 Edition. This deficient practice affects approximately 6 residents, staff, and visitors in 1 of 5 smoke zones. This facility has a capacity of 18 and a census of 2.

Findings include:

Observation and interview on 10/18/22 at 12:26 p.m., revealed that both the east and west corridor doors to the Pharmacy failed to positively latch within the door frames in order to keep the doors closed. This was due to the latching mechanisms being disabled. The Director of Facilities verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain electrical junction boxes in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code, 2011 Edition. This deficient practice affects approximately 1 staff in 1 of 5 smoke zones. This facility has a capacity of 18 and a census of 2.

Findings include:

Observation and interview on 10/18/22 at 12:57 p.m., revealed an open junction box with exposed electrical wiring located above ceiling at the entry to Med Surgery. The Director of Facilities verified this observation at the time of the survey process.

Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 18 and a census of 2.

Findings include:

Record review and interview on 10/18/22 at 9:35 a.m., revealed the facility was unable to provide fire drill documentation for the 2nd shift of the 3rd quarter for 2022. The Director of Facilities verified this observation at the time of the survey process.