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Based on observation and interview, the facility failed to provide an illuminated exit sign in the path of egress. This deficient practice had the potential delay or cause confusion during an emergency as occupants would not be aware of the exits. The facility census was 32 residents.

Findings are:
Observations on 3-20-18 at 2:09 PM revealed, while standing in the East Corridor by Receiving looking toward the north, no exit sign was visible to direct occupants to the North required exit.

During an interview on 3-20-18 at 2:09 PM, Maintenance Staff A confirmed the lack of exit signage.

NFPA Standard:
NFPA 101, 2012, 7.10.2.1*
A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

7.10.5.2.1
Every sign required to be illuminated by 7.10.6.3, 7.10.7, and 7.10.8.1 shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2.

Based on observation and interview, the facility failed to provide a smoke resistant enclosure for hazardous areas to separate them from the rest of the facility. The deficient practice would allow fire and smoke to migrate out of the hazardous areas into the exit corridor. Facility census was 32.

Findings are:

Observation on 3-20-18 between 1:10 PM and 1:58 PM revealed:

1. The door to Storage Room #243 was not equipped with a self-closing device. The room was 100 sq. ft. in area.
2. The door to Storage Room #G32 was not equipped with a self-closing device. The room was 80 sq. ft. in area.
3. A 6-inch diameter pipe in Pharmacy Storage Room #133 penetrated the ceiling and was not sealed.

During an interview on 3-12-18 at 9:57 AM and 10:38 AM, observation was acknowledged and verified by Maintenance A.


NFPA Standard:

Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2012 NFPA 101, 19.3.2.1 and 2012 NFPA 101, 8.4.1

Based on interview and record review, the facility failed to provide a complete policy regarding the procedures to be taken in the event that the fire alarm system was out of service for more than four hours in any twenty-four hour period. The lack of a complete written policy and procedure could result in staff failing to implement interim safety measures in the event of an emergency affecting all residents. Facility census was 32.

Findings are:

Record review of the Fire Watch Policy on 3-19-18 at 3:15 PM revealed:

1. The policy failed to provide the contact information for the State Fire Marshal and failed to state that the State Fire Marshal would be notified in the event of a fire watch.
2. The Fire Alarm Fire Watch Policy did not specify that the affected area would be continuously patrolled in the event a fire watch was instituted.
3. The Fire Alarm Fire Watch Policy did not specify that the designated person conducting the fire watch would be trained, and have no other duties while on fire watch.


During an interview on 3-19-18 at 3:15 PM, Administrator A confirmed lack of information in the fire watch policy.


NFPA 101, 2012 edition, 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on observation and interview, the facility failed to provide an intact ceiling to ensure activation of the sprinkler system at the designed temperature rating of the sprinklers, and failed to ensure that a fire sprinkler was free from all debris. These deficient practices did not ensure the sprinkler system was in operable condition and increased the potential that the system would not operate as designed. Facility census was 32.

Findings are:

Observation on 3-20-18 between 1:24 PM and 1:34 PM revealed:
1. A ceiling tile in Room #260, Med Sled was missing in the ceiling grid.

2. The fire sprinkler in Room #243 had paint on the deflector shield.

During an interview on 3-20-18 between 1:24 PM and 1:34 PM, observations were acknowledged and verified by Maintenance Staff A.

Based on interview and record review, the facility failed to ensure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure could result in staff failing to implement interim safety measures in the event of an emergency affecting all residents. Facility census was 32.

Findings are:

Record review of the Fire Watch Policy on 3-19-18 at 3:15 PM revealed:

1. The policy failed to provide the contact information for the State Fire Marshal and the Insurance Company.
2. The policy failed to state that the State Fire Marshal would be notified in the event of a fire watch.
3. The Fire Sprinkler Fire Watch Policy did not specify that the affected area would be continuously patrolled in the event a fire watch was instituted.
4. The Fire Sprinkler Fire Watch Policy did not specify that the designated person that conducted a fire watch would be trained, and have no other duties while on fire watch.


During an interview on 3-19-18 at 3:15 PM, Administrator A confirmed lack of information in the fire watch policy.

Based on documentation review and staff interview, the facility failed to hold fire drills under varied conditions for 4 of 4 quarters reviewed. This deficient practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect staff preparation and experience in providing for the protection of all residents in the event of a fire. The deficient practice affected all residents. The facility census was 32 residents.

Findings are:

Fire drill documentation review on 3-19-18 at 11:13 AM revealed:
1. Two of the second shift fire drills were conducted at 3:35 PM on 2-23-18 and 4:09 PM on 11-25-17.
2. Two of the first shift fire drills were conducted at 11:21 AM on 1-27-18 and 11:41 AM on 4-29-17.

During an interview on 3-19-18 at 11:13 AM, findings of documentation review were acknowledged and verified by Maintenance A.


NFPA Standard:
NFPA 101, 2012 Edition
19.7.1.6 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.

Based on observation and interview, the facility allowed the use of power strip in lieu of permanent wiring. This deficient practice increased the potential for an electrical fire. The facility census was 32.

Findings are:

Observation on 3-20-18 at 1:33 PM revealed a computer plugged into an extension cord in Room #259.

During an interview on 3-20-18 at 1:33 PM, observations were acknowledged and verified by Maintenance A.