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Based on record review and interview, the facility did not maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 Edition, 14.6.2.4, 14.3.1, and 14.4.5. The deficient practice of not conduction semi-annual inspections of the fire alarm system does not ensure proper operation and prompt repair, affecting all occupants. This facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Record review on 06/08/2023 at 1:05 p.m., of the fire alarm inspection and testing forms conducted by General Fire revealed the fire alarm system was inspected and tested on 01/28/2022, however, this inspection and testing of the fire alarm system was the last inspection located.

This defecient practice was confirmed by the Maintenance Supervisor.

Based on record review and interview, the facility failed to conduct the required biennial sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 14.4.5.3.2. This deficient practice affects all occupants as this lack of testing would not ensure the sensitivity of the detectors was within the manufacturer's specification. The facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Record review and interview on 06/08/2023 at 1:08 p.m., of the facility's fire alarm system inspection documentation, revealed the facility was unable to produce documentation that the sensitivity of the smoke detectors had been tested within the previous two years. Interview of the Maintenance Director indicated he thought the required sensitivity testing interval was done. The last documented sensitivity located was 09/20/2018. The Maintenance Director verified the documentation during the survey process.

Based on observation, record review and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments, are smoke resisting and are positive latching as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3. This deficient practice affected one of fifteen smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Observation on 06/08/2023, at 3:21 p.m., revealed the Storage Room door located in the Emergency Room to have a door wedge nearby on the floor.

Maintenance Staff confirmed the finding at the time of discovery.

Based on record review and interview, this facility is not providing proper documentation of inspection and testing of fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This deficient practice affects residents, staff, and visitors. This facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Record review and interview on 06/08/2023 at 2:11 p.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility completed within the last year. Interview of Maintenance Staff revealed the facility staff thought this was completed.

Maintenance Staff confirmed the documentation at the time of the survey.

NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.3 Functional Testing.

5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:

(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so
equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in
working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Based on record review and interview, the facility failed to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Record review on 06/08/2023 at 1:49 p.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator diesel fuel.

Maintenance Staff confirmed these findings at the time of the survey.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, by failing to use general precautions with power strips and surge protectors and allowing the use of non-approved electrical devices or adapters within the facility. These deficient practices affect residents, visitors, and staff in two of fifteen smoke compartments. The facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

1. Observation on 06/08/2023 at 2:41 p.m., revealed a surge protector providing power to a fridge, microwave, toaster, and coffee pot located in the Conifer Office. Maintenance Staff verified this observation at the time of the survey process.

2. Observation on 06/08/2023 at 3:11 p.m., revealed a surge protector providing power to a microwave and air fryer located in the C Wing Kitchenette. Maintenance Staff verified this observation at the time of the survey process.