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Based on observations and interview, the facility is not ensuring that its smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition, 19.3.7.3 and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects patients, staff, and visitors in two of 15 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

Observations and interview on 04/18/2016 at 1:50 p.m., revealed the smoke barrier above the door to the back hall to the Surgery Break Room contained an approximately one inch hole for seven blue communication wires and an approximately one inch hole for 1/2 inch tubing penetrating the wall above the lay in tile. According to the facility layout, this was a required barrier. The Director of Maintenance verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition, 19.7.1.2, for one of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 8.

Findings include:

Record review and interview on 04/18/2016 at 10:19 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct a fire drill during the first shift for the third quarter of 2015. Interview of the Director of Maintenance revealed a drill conducted during the third shift of the third quarter had probably been incorrectly transcribed for the first shift on the fire drill log sheet and facility staff thought it had been completed. The Director of Maintenance verified the documentation during the survey process.

Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition, 9.6.1.4 and NFPA Standard 72, National Fire Alarm Code, 1999 Edition, 1-5.2.5.2 by mechanically protecting the fire alarm dedicated branch circuit. This deficient practice affects all occupants of the building, including patients, staff, and visitors. This facility has a capacity of 25 with a census of 8.

Findings include:

Observation on 04/18/2016 at 12:02 p.m., revealed the fire alarm breaker, located in electrical Panel BEA Circuit #22 in the Basement Generator Room, was not secured with a mechanical lock. Interview of the Director of Maintenance revealed after the last survey, the dedicated fire alarm breaker had to be replaced so a mechanical lock could be installed on it and it had been completed. The Director of Maintenance stated a contractor may have removed it to work on the electrical panel but then never reinstalled it. The Director of Maintenance verified this observation during the survey.

Based on observation and interview, the facility failed to maintain a complete and automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1999 Edition. This deficient practice could affect any staff and patients in the affected room. The facility has a capacity of 25 and a census of 8.

Findings include:

Observation and interview on 04/18/2016 at 12:37 p.m., revealed the sprinkler head in the center of the ceiling of the Radiology 1 X-ray Room was missing the escutcheon ring. This missing escutcheon ring could cause a delay or failure in the operation of the sprinkler head. The Director of Maintenance confirmed this observation at the time of the survey.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 Edition. This deficient practice affects patients, staff, and visitors in one of 15 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings Include:

Observation and interview on 04/18/2016 at 1:45 p.m., revealed the facility failed to maintain the electrical system in the corridor above the double doors outside of Central Supply. This corridor contained an open four inch by four inch junction box with exposed wires on the west side of the smoke barrier above the ceiling tiles. The Director of Maintenance verified this observation at the time of the survey.

Based on observations and interview, the facility is not ensuring that its smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition, 19.3.7.3 and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects patients, staff, and visitors in two of 15 smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

Observations and interview on 04/18/2016 at 1:50 p.m., revealed the smoke barrier above the door to the back hall to the Surgery Break Room contained an approximately one inch hole for seven blue communication wires and an approximately one inch hole for 1/2 inch tubing penetrating the wall above the lay in tile. According to the facility layout, this was a required barrier. The Director of Maintenance verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition, 19.7.1.2, for one of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 8.

Findings include:

Record review and interview on 04/18/2016 at 10:19 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct a fire drill during the first shift for the third quarter of 2015. Interview of the Director of Maintenance revealed a drill conducted during the third shift of the third quarter had probably been incorrectly transcribed for the first shift on the fire drill log sheet and facility staff thought it had been completed. The Director of Maintenance verified the documentation during the survey process.

Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition, 9.6.1.4 and NFPA Standard 72, National Fire Alarm Code, 1999 Edition, 1-5.2.5.2 by mechanically protecting the fire alarm dedicated branch circuit. This deficient practice affects all occupants of the building, including patients, staff, and visitors. This facility has a capacity of 25 with a census of 8.

Findings include:

Observation on 04/18/2016 at 12:02 p.m., revealed the fire alarm breaker, located in electrical Panel BEA Circuit #22 in the Basement Generator Room, was not secured with a mechanical lock. Interview of the Director of Maintenance revealed after the last survey, the dedicated fire alarm breaker had to be replaced so a mechanical lock could be installed on it and it had been completed. The Director of Maintenance stated a contractor may have removed it to work on the electrical panel but then never reinstalled it. The Director of Maintenance verified this observation during the survey.

Based on observation and interview, the facility failed to maintain a complete and automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1999 Edition. This deficient practice could affect any staff and patients in the affected room. The facility has a capacity of 25 and a census of 8.

Findings include:

Observation and interview on 04/18/2016 at 12:37 p.m., revealed the sprinkler head in the center of the ceiling of the Radiology 1 X-ray Room was missing the escutcheon ring. This missing escutcheon ring could cause a delay or failure in the operation of the sprinkler head. The Director of Maintenance confirmed this observation at the time of the survey.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 Edition. This deficient practice affects patients, staff, and visitors in one of 15 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings Include:

Observation and interview on 04/18/2016 at 1:45 p.m., revealed the facility failed to maintain the electrical system in the corridor above the double doors outside of Central Supply. This corridor contained an open four inch by four inch junction box with exposed wires on the west side of the smoke barrier above the ceiling tiles. The Director of Maintenance verified this observation at the time of the survey.