HospitalInspections.org

Based on observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.2.1.1.1 and Section-5.2.1.1.2), 2011 Edition. These deficient practices affect all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 1.


Findings include:

Observation and interview on 04/30/25 at 10:42 a.m., revealed in the dishwashing are of the kitchen a sprinkler had excessive corrosion buildup on the sprinkler, arms, and diffuser.

Maintenance verified this observation during the survey.

Based on record review and interview, the facility failed to provide an adequate outage policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.5.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 1.

Findings include:

Record review and interview on 04/30/25at 10:00 a.m., revealed the provided Sprinkler Outage Policy for the system being out of service for 10 or more hours in a 24 hour period did not designate an Impairment Coordinator. The policy did not address the extent and expected duration of the impairment and that the areas of the building involved have been inspected and increased risks determined. The policy did not address tagging of the impaired system. Nor did the policy address emergency impairments such as system leakage, interruption of water supply, ruptured piping, or other equipment failure.

The Administrator and Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure that smoke barriers are free of penetrations which would prevent the passage of smoke to an adjacent smoke compartment in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-8.5.6.2), 2012 Edition. This facility has a capacity of 25 and a census of 1.

Findings include:

Observation on 4/30/25, at 10:42 a.m., revealed a 1/2 ceiling penetration in the dishwashing room of the kitchen.

Maintenance verified this observation during the survey.

Based on record review and interview, the facility is not conducting drills on a random basis in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.4), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity 25 and a census of 1.

Findings include:

Record review and interview on 04/30/25 at 10:28 a.m., revealed the facility failed to vary the times fire drills are conducted. Documentation provided indicates the drills on 2nd shift were consistently being conducted at 2:30 p.m.

Administrative Staff and Maintenance Staff verified this observation at the time of the survey process.