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Based on record review and staff interview the facility failed to verify the DACT signal as required by the Life Safety Code,(LSC) 2012 edition, section 9.6.1.3 and NFPA 72, The National Fire Alarm and Signaling Code, 2010 edition, table 14.3.1. This deficient condition could delay alarm notification to emergency personnel in case of a failure and affect all 34 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 1:00 pm on 06/13/2018 record review and staff interview revealed the DACT signal was not being verified.

This deficient condition was confirmed by the Facility Administrator and the Facility Manager.

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the Fire Alarm system has to be placed out-of-service for four or more hours in a 24 hour period. As per NFPA 101 Life Safety Code (12) section 9.6.1.6. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of of all 34 patients as well as an undetermined number of staff, and visitors to the facility .

Findings include:

On the facility tour between 8:00 am to 1:00 pm on 06/13/2018 documentation review revealed there was no record of a fire alarm system out of service policy.

This deficient condition was confirmed by the Facility Administrator and the Facility Manager.

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for ten or more hours in a 24 hour period as per NFPA 25. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all 34 residents as well as an undetermined number of staff, and visitors to the facility .

Findings include:

On the facility tour between 7:30 am to 12:00 pm on 06/12/2018 documentation review revealed there was no record of a fire sprinkler system out of service policy.

This deficient condition was confirmed by the Facility Administrator and the Facility Manager.

Based on record review and staff interview the facility failed to maintain a Fire Safety Plan as required in NFPA 101 Life Safety Code, 2012 edition section 19.7.2.2. This deficient practice could cause confusion in an emergency and affect all 34 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 1:00 pm on 06/13/2018 record review and staff interview revealed the evacuation plan did not address all 9 items required by the Life Safety Code.

This deficient condition was confirmed by the Facility Administrator and the Facility Manager.

Based on record review and staff interview the facility failed to perform effective fire drills quarterly on each shift as required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all 34 patients and an undetermined amount of staff and visitors.

Findings include:

Documentation review revealed staff commented on the fire drill reports they did not know where to evacuate to and did not know where the nearest fire extinguishers were.
Several staff were interviewed and they commented, they were not sure where to evacuate to in case of a fire.
A fire drill was conducted during the inspection and staff appeared to be unsure of what the procedure was. Two staff interviewed by the Health Surveyors did not recognize the alarm sound and asked them what they should do.

This deficient condition was confirmed by the Facility Administrator and the Facility Manager.

Based on observation and staff interview, the facility has failed to provide a complete and current facility Risk Assessment in accordance with the NFPA 99 "Health Care Facilities Code" 2012 edition section 4.1. This deficient practice could affect all patients, as well as an undetermined number of staff, and visitors.


Findings include:

On the facility tour, between 8:00 am to 1:00 pm on 06/13/2018 , during record review the facility was not able to provide a risk assessment document based on NFPA 99.

This deficient condition was confirmed by the Facility Administrator and the Facility Manager.