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Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting all residents, visitors and staff in 2 of 5 smoke zones. The facility has a capacity of 20 with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 09/14/2015 at 3:00 p.m., it is observed that the smoke barrier wall near the cafeteria has an unsealed penetration around piping,

Director of Plant Operations was present and acknowledged that the unsealed opening was present.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting all patients, visitors and staff in 1 of 5 zones. The facility has a capacity of 20 with a census of 6 at the time of this survey.

Findings include:

During the tour conducted on 09/14/2015, at approximately 3:07 p.m., it is observed that medical equipment is stored in patient corridors, reducing the exit pathway to approximately 6 feet.

Director of Plant Operations was present and acknowledge the findings.

NFPA Standard: Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

Based on record review and staff interview, the facility fails to provide a remote shut-off for the generator. These deficient practices could result the inability to remotely discontinue electrical services of the generator to avoid electrocution. The deficient practice could affect all residents and any staff or visitors in 5 of 5 smoke zones. The facility has a capacity of 20 with a census of 6 at the time of this survey.

Findings include:

During the tour conducted on 09/14/2015, at approximately 3:55 p.m., it is observed that there is no remote shut-off provided for the automatic generator.

Director of Plant Operations was present and acknowledged that no remote shutoff is provided for the automatic diesel generator.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70 and fails to prohibit the use of flexible cords and cables as permanent wiring. The deficient practice increases the risk of an electrical fire, affecting approximately no patients and any visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 20 with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 09/14 /2015, at approximately 4:00 p.m., in Central Supply, it is observed that one powerstrip is used to power another powerstrip.

Director of Plant Operations was present and acknowledged the unacceptable use of an extension cord.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting all residents, visitors and staff in 2 of 5 smoke zones. The facility has a capacity of 20 with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 09/14/2015 at 3:00 p.m., it is observed that the smoke barrier wall near the cafeteria has an unsealed penetration around piping,

Director of Plant Operations was present and acknowledged that the unsealed opening was present.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting all patients, visitors and staff in 1 of 5 zones. The facility has a capacity of 20 with a census of 6 at the time of this survey.

Findings include:

During the tour conducted on 09/14/2015, at approximately 3:07 p.m., it is observed that medical equipment is stored in patient corridors, reducing the exit pathway to approximately 6 feet.

Director of Plant Operations was present and acknowledge the findings.

NFPA Standard: Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

Based on record review and staff interview, the facility fails to provide a remote shut-off for the generator. These deficient practices could result the inability to remotely discontinue electrical services of the generator to avoid electrocution. The deficient practice could affect all residents and any staff or visitors in 5 of 5 smoke zones. The facility has a capacity of 20 with a census of 6 at the time of this survey.

Findings include:

During the tour conducted on 09/14/2015, at approximately 3:55 p.m., it is observed that there is no remote shut-off provided for the automatic generator.

Director of Plant Operations was present and acknowledged that no remote shutoff is provided for the automatic diesel generator.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70 and fails to prohibit the use of flexible cords and cables as permanent wiring. The deficient practice increases the risk of an electrical fire, affecting approximately no patients and any visitors and staff in 1 of 5 smoke zones. The facility has a capacity of 20 with a census of 6 at the time of the survey.

Findings include:

During the tour conducted on 09/14 /2015, at approximately 4:00 p.m., in Central Supply, it is observed that one powerstrip is used to power another powerstrip.

Director of Plant Operations was present and acknowledged the unacceptable use of an extension cord.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8