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Based upon a review of records, observation and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all residents, staff and visitors in 7 of 7 smoke zones. The facility has a capacity of 28 with a census of 5 at the time of this survey.

Findings include:

During the tour conducted on 05/19/2014, a review of records between 12:30 p.m. and 1:30 p.m., for the last five quarters, revealed the following:

-- 1. No documented monthly visual inspections of the automatic sprinkler system for the months of November and December 2013.

Maintenance Staff A was present and acknowledged the results of the records review.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based upon a review of records and staff interview, the facility fails to assure that anesthetizing locations are protected in accordance with NFPA 99. The deficient practice increases the risk of fire or explosion affecting approximately 2 patients in 1 of 7 smoke zones. The facility has a capacity of 28 with a census of 5 at the time of this survey.

Findings include:

During the tour conducted on 05/19/2014, at approximately 4:00 p.m., it is observed that the relative humidity of each of two operating/procedure rooms is not sufficiently documented to determine whether or not relative humidity is maintained equal to or greater than 35%.

Director of Plant Facilities, Maintenance Staff A and Maintenance Staff B were present and acknowledged the results of the records review.

NFPA Standard: Anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities. Relative humidity is maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3

Based upon a review of records, observation and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all residents, staff and visitors in 7 of 7 smoke zones. The facility has a capacity of 28 with a census of 5 at the time of this survey.

Findings include:

During the tour conducted on 05/19/2014, a review of records between 12:30 p.m. and 1:30 p.m., for the last five quarters, revealed the following:

-- 1. No documented monthly visual inspections of the automatic sprinkler system for the months of November and December 2013.

Maintenance Staff A was present and acknowledged the results of the records review.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based upon a review of records and staff interview, the facility fails to assure that anesthetizing locations are protected in accordance with NFPA 99. The deficient practice increases the risk of fire or explosion affecting approximately 2 patients in 1 of 7 smoke zones. The facility has a capacity of 28 with a census of 5 at the time of this survey.

Findings include:

During the tour conducted on 05/19/2014, at approximately 4:00 p.m., it is observed that the relative humidity of each of two operating/procedure rooms is not sufficiently documented to determine whether or not relative humidity is maintained equal to or greater than 35%.

Director of Plant Facilities, Maintenance Staff A and Maintenance Staff B were present and acknowledged the results of the records review.

NFPA Standard: Anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities. Relative humidity is maintained equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3