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Based on observation and interview, this facility is not maintaining a 2-hour fire barrier in accordance with National Fire Protection Association (NFPA) Standard 101 (Section 19.1.1.4.1), Life Safety Code, 2000 Edition. This deficient practice affects approximately 4 residents, staff, and visitors in one of eight smoke zones. This facility has a capacity of 25 and a census of 3.

Findings include:

1. Observation and interview on 01/05/16 at 10:24 a.m., revealed an approximate 1/2 inch gap around communication wires that penetrate the 2-hour fire barrier above the lay in ceiling tile between the Hospital and Dialysis Center.

2. Observation and interview on 01/05/16 at 10:24 a.m., revealed a 1/2 inch open to the center conduit that penetrates the 2-hour fire barrier above the lay in ceiling tile between the Hospital and Dialysis Center. The Director of Plant Operations and Chief Financial Officer verified these observations at the time of the survey process.

Based on observation, interview, and record review, the facility failed to maintain the battery back-up emergency egress lights. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 3.

Findings include:

1. Record review and interview on 01/05/16 at 9:50 a.m., revealed the facility could not provide a date for the annual 90 minute testing of the emergency lights.

2. Observation and interview on 01/05/16 at 10:48 a.m., revealed the emergency light near the Southeast exit of the Physical Therapy Track Area failed when tested.

3. Observation and interview on 01/05/16 at 10:55 a.m., revealed the emergency light above the south door of the TWC Mechanical Room failed when tested.

4. Observation and interview on 01/05/16 at 10:57 a.m., revealed the emergency light along the west wall of the TWC Mechanical Room failed when tested. The Director of Plant Operations and Chief Financial Officer verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 72 (A.5.7.4.1), National Fire Alarm Code, 1999 Edition, which requires that smoke detectors not be located in a direct airflow or closer than three feet from an air supply diffuser or return air opening. This deficient practice affects all occupants in the facility, as smoke detectors located within three feet of a direct air flow, air supply diffuser, or air return opening can impede the operation of the detector. This facility has a capacity of 25 and a census of 3.

Findings include:

Observation and interview on 01/05/16 at 11:22 a.m., revealed the Waiting Area outside the Gift Shop contained a smoke detector that was located within 3 feet of an air diffuser. The Director of Plant Operations and Chief Financial Officer verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain and test the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 3.

Findings include:

Record review and interview on 01/05/16 at 10:08 a.m., revealed the facility could not provide documentation for a 5-year internal obstruction inspection of the sprinkler system. The Director of Plant Operations and Chief Financial Officer verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 Edition. This deficient practice affects approximately 4 staff in one of eight smoke zones. This facility has a capacity of 25 and a census of 3.

Findings include:

1. Observation and interview on 01/05/16 at 10:33 a.m., revealed the Clean Utility Room contained an electrical outlet within six feet of the sink that was not GFCI (Ground Fault Circuit Interrupter) protected.

2. Observation and interview on 01/05/16 at 10:37 a.m., revealed the Acute Care Nourishment Area contained two electrical outlets within six feet of the sink that were not GFCI (Ground Fault Circuit Interrupter) protected. The Director of Plant Operations and Chief Financial Officer verified these observations at the time of the survey process.