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Based on observation and staff interview, the facility failed to ensure all components of the fire sprinkler system were correctly installed and maintained. This deficient practice would delay activation of the sprinkler system allowing fire, smoke and gases to spread affecting occupants in 5 of 7 smoke compartments. Facility census was 7 and licensed for 20 at time of survey.

Findings are:
Observation on 12-3-2019 between 10:45 AM and 12:15 PM revealed the following:

1) Recessed fire sprinkler missing an escutcheon in Physical Therapy Staff Breakroom.
2) Recessed fire sprinkler missing an escutcheon in Emergency room #2.
3) Recessed fire sprinkler missing an escutcheon in Physical Therapy Staff Breakroom.
4) Recessed fire sprinkler missing an escutcheon in Radiology room above desk.
5) 2 recessed fire sprinklers missing escutcheons in Trash collection room near the oxygen storage.


During interview on 12-3-2019 at 12:15 PM, Maintenance Staff A confirmed the sprinkler conditions.

Based on record review and staff interview, the facility failed to conduct fire drills for each shift. These conditions did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, affecting all occupants in all 7 smoke compartments. The facility census was 7 and licensed for 20 at time of survey.

Findings are:
Record review on 12-3-2019 at 9:15 AM revealed the following:

A fire drill was not recorded for the third shift (10:00 PM - 7:00 AM) in the third quarter of 2019 (July - September).

During an interview on 12-3-2019 at 9:15 AM, Maintenance Staff A confirmed no fire drill was conducted.

Based on observations and staff interview, the facility failed to ensure electrical junction boxes were equipped with cover plates. This deficient practice could cause an electrical injury or fire, affecting occupants in 1 of 7 smoke compartments. Facility census was 7 and licensed for 20 at time of survey.

Finding are:
Observation on 12-3-2019 at 11:55 AM revealed the following:

An open low voltage electrical junction box was located in the Softener/Sprinkler Riser room.

NFPA 70-314.28.C

During interview on 12-3-2019 at 11:55 AM, Maintenance Staff A confirmed the open junction box.

Based on observation and staff interview, the facility failed to ensure gas equipment was secured when not in use. This deficient practice could cause the potential for rapid fire growth within the room in the event of cylinder falling over, which would have affected approximately 2 occupants in 1 of 7 smoke compartments. Facility census was 7 and licensed for 20 at time of survey.

Finding are:
Observations on 12-3-2019 at 11:35 AM revealed the following:

One oxygen cylinder, not restrained or in a hand truck, was observed in the North Emergency Room office.

During interview on 12-3-2019 at 11:35 AM, Maintenance Staff A confirmed that the cylinder was not restrained.

NFPA 99-11.4.3.1.1 2012 edition, Carts and hand trucks for cylinders and containers shall be constructed for the intended purpose, be self-supporting, and be provided with appropriate chains or stays to retain cylinders or containers.