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Based on observation and interview, the facility failed to maintain the 1-hour separation, and to assure the door to a hazardous area would close and latch within the doorframe. This deficient practice would allow fire, smoke and gasses to migrate into the exit corridors. The facility has the capacity for 23 beds with a census of 9 on the day of survey.

Findings are:

Observation on 01-07-20 at 11:25 am revealed the door to the Utility/Soiled Linen room failed to fully close and latch within the door frame.

During an interview on 01-07-20 at 11:25 am, Maintenance Staff A confirmed the findings.

Based on record review and staff interview, the facility failed to have the smoke detector sensitivity test conducted every other year, or every five years with associated documentation for the fire alarm system. This practice increased the potential that the fire alarm would fail to detect smoke from a fire. The facility has the capacity for 23 beds with a census of 9 on the day of survey.

Findings are:
Record review on 01-07-20 at 10:15 am revealed a smoke detector sensitivity test was not conducted in the last 2 years, or every five years with supporting documentation. The last documented sensitivity testing was conducted in June of 2017.

In an interview on 01-07-20 at 10:15 am, Maintenance Staff A acknowledged a more recent report was not available for review.

NFPA 72, 2010, 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year
thereafter unless otherwise permitted by compliance with
14.4.5.3.3.
14.4.5.3.3 After the second required calibration test, if sensitivity
tests indicate that the device has remained within its
listed and marked sensitivity range (or 4 percent obscuration
light gray smoke, if not marked), the length of time between
calibration tests shall be permitted to be extended to a maximum
of 5 years.
14.4.5.3.3.1 If the frequency is extended, records of nuisance
alarms and subsequent trends of these alarms shall be maintained.
14.4.5.3.3.2 In zones or in areas where nuisance alarms show
any increase over the previous year, calibration tests shall be
performed

Based on observation and interview, the facility failed to provide and maintain all required equipment and appurtenances for the fire sprinkler system. This deficient practice could impact the response time and effectiveness of the sprinkler system. The facility has the capacity for 23 beds with a census of 9 patients on the day of survey.

Findings are:
Observation on 01-07-20 at 11:17 am revealed a missing escutcheon on the sprinkler in patient room number 1.

During an interview on 01-07-20 at 11:17 am, Maintenance Staff A confirmed the findings.

Based on observation, record review and staff interview, the facility failed to inspect all portable fire extinguishers. This deficient practice increased the potential that a fire extinguisher would fail to operate during a fire. The facility has the capacity for 23 beds with a census of 9 on the day of survey.

Findings are:
Observation on 01-07-20 at 10:22 am revealed the inspection tag for the fire extinguisher in the basement had not been inspected in the month of December, 2019.

In an interview on 01-07-20 at 10:22 am, Maintenance Staff A acknowledged the fire extinguisher was not inspected.

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