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Based on record review and staff interview the facility fails to assure fire extinguishers are serviced annually in accordance with NFPA 10. This deficiency practice fails to ensure that a fire extinguisher will be in proper working condition when needed in the event of a fire emergency, affecting 0 residents in one of six smoke zones. The facility has a capacity of 25 with a census of 11.

Findings include:

During the survey on May 16, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. At 10:42 AM fire extinguisher located in boiler room is under-charged
2. At 10:45 AM fire extinguisher located in the purchasing office is missing monthly checks.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2012 NFPA 101, 9.7.4.1*

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting 0 residents in one of six smoke zones. The facility has a capacity of 25 with a census of 11.

Findings include:

During the survey on May 16, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. At 12:21 PM an extension cord is being used as permanent wiring to power a refrigerator in the instrument room.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.1.2

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents in all six smoke zones. The facility has a capacity of 25 with a census of 11.

Findings include:

During the record review on May 16, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. Record review revealed that no scenarios are documented for the fire drills performed in May and June of 2016.

2. Record review revealed that no 2nd shift fire drill was performed in the 1st quarter of 2017.

3. Record review revealed that the 3rd shift fire drills for September and November of 2016 and January of 2017 were all performed between 4:00 AM and 4:45 AM.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. and
6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Review of the following NFPA Standard revealed: The basic response required of staff shall include the following:

(1) Removal of all occupants directly involved with the fire Emergency

(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff

(3) Confinement of the effects of the fire by closing doors to isolate the fire area

(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

2012 NFPA 101, 19.7.2.1.2