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Based on record review and staff interview, the facility failed to maintain the commercial hood & duct extinguishing system in the Kitchen in accordance with National Fire Protection Association (NFPA) 96. This deficient practice affects all occupants in 1 of 19 zones. The facility has a capacity of 25 and a census of 5.

Findings include:

Record review and interview on 12/05/24 at 2:55 p.m. revealed the last commercial hood & duct extinguishment system service occurred on 07/18/23 instead of semi-annually as required.

Maintenance Staff A & B acknowledged this finding.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition. This deficient practice affected all occupants in 1 of 19 zones. The facility has a capacity of 25 and a census of 5 patients at the time of the survey.

Findings include:

Record review and interview on 12/05/24 at 3:18 p.m. revealed the Blackhawk Sprinkler report dated 03/14/24 stated, "Notes: Found approximately 60 1967 heads in basement are past due for testing or replacement". The facility failed to provide documentation indicating these 60 heads had been replaced.

Maintenance Staff A & B acknowledged this finding.

Based on observation and interview, the facility did not ensure corridor doors fit tightly within the doorframe to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.6.3. This deficient practice affected all occupants in 1 of 19 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 5 patients at the time of the survey.

Findings include:

Observation and interview on 12/05/24 at 2:51 p.m. revealed the door to the Wash Room in the Basement was missing latching hardware.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to provide smoke barrier doors that resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, 2012 edition, section 19.3.7.6, 19.3.7.8, & 19.3.7.9. This deficient practice affects all occupants in 2 of 19 zones. The facility has a capacity of 25 and a census of 5 patients.

Findings include:

Observations and interview on 12/05/24 at 2:27 p.m. revealed the east smoke barrier doors to Comp Specialty failed to close and latch properly.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70, 2011 edition. This deficient practice affects all occupants in 2 of 19 zones. The facility has a capacity of 25 and a census of 5.

Findings include:

Observations and interview on 12/05/24 revealed the following electrical system deficiencies:

1. At 1:50 p.m. an open knockout in the electrical junction box serving the fire alarm system annunciator located in the Maintenance Shop in the Basement.
2. At 2:20 p.m. an open electrical junction box located in the Shredder Bin Room.
3. At 2:21 p.m. an open knockout in the electrical junction box located above the Morgue Cooler.

Maintenance Staff A observed this finding.