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Based on observation and staff interview, the facility is not providing unobstructed exiting from one room. This deficient practice effects all residents, staff and visitors in that room. This facility has a capacity of 25 with a census of 5 residents.

Findings include:

Observation and interview on 10/10/19 at 12:19 p.m., revealed the door to the Family Room, across from Resident Room #101, had a door knob with a latch and an additional locking device above the knob. This requires two movements to open the door. Maintenance Staff A verified the observation.

Based on record review and interview the facility failed to provide documentation for the sensitivity testing of the smoke detectors. This deficient practice effects all occupants including staff in visitors in the building. The facility has a certified capacity of 25 with the current census of 5 residents.

Findings include:

Record review and interview on 10/10/19 at 11:15 a.m., revealed the fire alarm inspection documentation from the last two years did not show smoke detector sensitivity testing being completed as required. Maintenance Staff A verified this finding.

Based on interview and record review, this facility did not assure that a complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affected all occupants of the building. This facility had a capacity of 25 and a census of 5 residents at the time of the survey.

Findings include:

Record review and interview on 10/10/19, at 11:37 a.m., of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 10 hours in a 24-hour period. The policy failed to have the following information included in their policy as required by NFPA 25, 2011 Edition (Chapter 15):



15.3 Tag Impairment System.
15.3.1* A tag shall be used to indicate that a system, or part thereof, has been removed from service.
15.3.2* The tag shall be posted at each fire department connection and the system control valve, and other locations required by the authority having jurisdiction, indicating which system, or part thereof, has been removed from service.
15.4 Impaired Equipment.
15.4.1 The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service.
15.4.2 The impaired equipment shall include, but shall not be limited to, the following:
(1) Sprinkler systems
(2) Standpipe systems
(3) Fire hose systems
(4) Underground fire service mains
(5) Fire pumps
(6) Water storage tanks
(7) Water spray fixed systems
(8) Foam-water systems
(9) Fire service control valves

15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.

15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.

15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

15.7 Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:

(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed.

Maintenance Staff A confirmed the findings during the exit conference.

Based on observation, record review and interview, this facility did not maintain the diesel emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition,. The facility did not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards The facility also did not provide a remote stop for the generator. The deficient practices of not providing complete maintenance of the generator did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 25 and a census of 5 residents at the time of the survey.

Findings include:

Record review and interview conducted on 10/10/19 at 11:37 a.m., of the facility's generator inspection testing and maintenance records revealed:

1. The facility could not provide documentation of an annual fuel quality test for the generator diesel fuel.

2. The facility did not have a remote manual stop for the generator located away from the generator.

These deficient practices were confirmed by Maintenance Staff A at the time of observation and exit.

Based on observation and interview, the facility did not store oxygen tanks in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 11.6.5, by ensuring empty and full tanks were adequately separated and labeled to prevent confusion when choosing tanks in an emergency. This deficient practice occurred in two oxygen storage room and affected all occupants. This facility had a capacity of 25 and a census of 5 residents at the time of the survey.

Findings include:

Observation and interview on 10/10/19 at 12:12 p.m., revealed the Oxygen Storage Rooms contained multiple " E " cylinders that were not located physically separate or appropriately labeled full and empty. This deficient practice was confirmed by Maintenance Staff A at the time of discovery.