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Based on record review and interview, the facility failed to document periodic testing of emergency lighting equipment in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.2.9.1 and 7.9.3. This deficient practice affects light fixtures in the facility. The facility had a capacity of 25 and a census of 12 residents at the time of the survey.

Findings include:

Record review on 07/18/2023 at 9:44 a.m., revealed the facility was unable to provide documentation of monthly functional testing for any battery backup emergency light fixture throughout the building. The facility could provide documentation of annual 90 minute testing done on 07/14/2022.

The Maintenance Supervisor confirmed these findings during the survey process.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all staff who may be in the Kitchen. The facility had a capacity of 25 and a census of 12 at the time of the survey.

Findings include:

Observation on 07/18/2023 at approximately 11:21 a.m., revealed the facility failed to maintain the sprinkler system in the Kitchen. Nine sprinkler heads contained dust and lint throughout. The Maintenance Staff confirmed this finding during the survey process.

Based on record review and interview, this facility is not providing proper documentation of inspection and testing of fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This deficient practice affects residents, staff, visitors in the facility. This facility had a capacity of 25 and a census of 12 residents at the time of the survey.

Findings include:

Record review on 07/18/2023 at 10:08 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility for the last year. The last documented test was conducted on 08/01/2019. Interview of Maintenance Staff revealed the facility staff was unaware of the inspection requirement and verified this finding during the survey.


NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.3 Functional Testing.

5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:

(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so
equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in
working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, by failing to use general precautions with power strips and surge protectors and allowing the use of non-approved electrical devices or adapters within the facility. These deficient practices affect residents, visitors, and staff in three the facility. The facility had a capacity of 25 and a census of 12 residents at the time of the survey.

Findings include:

1. Observation on 07/18/2023 at 10:43 a.m., revealed a surge protector providing power to a fridge in the Facility Director's Office. Maintenance Staff verified this observation at the time of the survey process.

2. Observation on 07/18/2023 at 10:43 a.m., revealed a blue extension cord providing power to a window air unit in the Facility Director's Office. Maintenance Staff verified this observation at the time of the survey process.

3. Observation on 07/18/2023 at 11:10 a.m., revealed a surge protector providing power to a toaster and microwave in the Laboratory Lounge. Maintenance Staff verified this observation at the time of the survey process.

4. Observation on 07/18/2023 at 11:37 a.m., revealed a surge protector providing power to a microwave, toaster, and fridge in the EVS Break Room. Maintenance Staff verified this observation at the time of the survey process.