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Based on observation and interview, the facility failed to provide illumination of the means of egress in accordance with the requirements of NFPA 101 (2012 edition), 7.8.1.4. The deficient practice could affect all patients and an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 4/17/17 at 3:28 pm, observation revealed that the Common Area East Exit discharge was not illuminated with a lighting fixture with two bulbs, or two lighting fixtures so that a failure of any single bulb would still provide the required minimum illumination levels in the exit path.

The above deficiency was confirmed by the concurrent observation and interview with Staff B (director of environmental services), Staff A (deputy director) and Staff C (director of nursing) at the time of exit conference on 4/17/17 at 4:30 pm.

Based on observation, record review and staff interview, the facility failed to properly protect one cooking equipment in accordance with NFPA 101 (2012) 18.3.2.5.1, NFPA 96 (2011) 10.4. This deficient practice had a potential to affect an undetermined number of patients, staff and visitors in the facility.

FINDINGS INCLUDE

On 4/17/17 at 11:30 am, while on a tour of the facility and review of the fire-suppression system maintenance records with Staff B (director of environmental services), observation revealed that the electrical steamer located under the hood in the Kitchen was not arranged to have automatic electrical power shut-off upon activation of the fire-suppression system that protected cooking appliances under the hood. The maintenance record of the fire-suppression system showed that the electrical power shut-off row on the inspection report was checked "N/A".

The above deficiency was confirmed by the concurrent observation, record review and interview with Staff B, Staff A (deputy director) and Staff C (direcor of nursing) at the time of exit conference on 4/17/17 at 4:30 pm.

Based on record review and staff interview, the facility failed to provide a properly tested fire alarm system in accordance with the NFPA 72 Chapters 14 Tables 14.4.2.2 (18) and Table 14.4.5 (22) requirements on annual testing of transmission and receiving equipment to provide annunciation of trouble signals from phone line failure; and to perform visual linspection of smoke and heat detectors in accordance with NFPA 72 14.3.1 Table 14.3.1. The deficient practice affects all patients, staff and visitors.

FINDINGS INCLUDE

1. On 4/17/17, a review of the fire alarm system maintenance records with Staff B (director of environmental services) revealed that the automatic dialer component of the facility fire alarm system was not annually tested for audible and visible trouble signals caused by phone line failure. When interviewed on 4/17/17 at 2:15 pm, Staff B stated that there were two dedicated phone lines to transmit fire alarm signals to the monitoring station, Priority One.

2. On 4/17/17, during a record review of the fire alarm system maintenance records with Staff M, it was revealed that the semiannual visual inspections of smoke, duct smoke, and heat detectors were not documented. When interviewed at 2:15 pm on 4/17/17, Staff B stated that an inspection of the detectors was performed but a record of inspection was not kept.

The above condition was confirmed at the time of discovery by a concurrent review of maintenance record and interview with Staff B, Staff A (deputy director) and Staff C(director of nursing) at the time of exit conference on 4/17/17 at 4:30 pm.