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Based on observation, record review and interview this facility did not provide complete sprinkler coverage as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.5.1 and 9.7. This one-story building is composed of unprotected combustible construction and is not completely sprinklered. This deficient practice affected approximately 3 occupants in one of eight smoke zones. This facility had a capacity of 25 and a census of 3 at the time of the survey.

Findings include:

Observation on 8/11/22, at 1:39 p.m., revealed the 200 Wing Housekeeping closet was not protected with sprinkler coverage. The lack of sprinkler coverage could delay or prevent the extinguishment of a fire. Record review of the facility layout showed the deficient practice affected one of eight smoke zones.

Maintenance Staff confirmed the observation at the time of discovery.

Based on observation and staff interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, placing the Staff and 17 Residents in two of four smoke zones at risk in the event of a fire. The facility had a capacity of 25 and a census of 3 at the time of the survey.

Findings Include:

Observation and staff interview on 8/11/21 at 1:43 p.m. revealed the facility failed to provide approved GFCI (Ground Fault Circuit Interrupter) outlet next to water source in the 100 Wing Housekeeping Closet.
Maintenance Staff verified this observation during the survey process.

Based on record review and interview, the facility failed to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

Record review and interview on 8/11/22, at 3:19 p.m., revealed the facility could not provide documentation of a 2022 annual fuel quality test for the generator diesel fuel. The last fuel quality test was performed on 7/14/21.

Maintenance Staff confirmed this finding at the time of the survey.