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Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 0 of 0 residents.
1 of 2 corridors has emergency lighting that is deficient.

Findings:

During the facility tour, between the hours of 8:00AM to 12:00PM it was observed that only one emergency light that was located on the back hall between the men and womens restroom was functioning. All other emergency lights did not function.

Interview with the Administrator revealed the facility was not aware that the emergency lighting on throughout the facility was compromised.

Based on visual observation the facility failed to assure that the fire alarm system was installed to provide effective warning to all parts of the building. The devices installed for the system's activation shall be by manual, detection or extinguishing operation which gives a sense of security to offer an advance warning in an emergency. This deficiency could potentially affect 0 of 0 residents.

Findings:

During the facility tour and the record review, between the hours of 8:00AM to 12:00PM it was observed that a manual pull station was located at the front exit. It was found that the building did not have a fire alarm and that at one time this facility was connected to a fire alarm in the facility directly beside it. However these two buildings are no longer operated together and have different tenants/owners. The staff stated that the pull does not work at all to there knowledge.

Interview with the administrator revealed the facility was not aware that the device had been previously conected to a fire alarm.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 12 of 12 residents.

Findings:

During the facility tour, between the hours of 9:00AM to 3:30PM on 4/20/2017 and 1:00PM to 5:00PM on 4/21/2017 it was observed that the sprinkler system had been last inspected on 3/28/2016 by Advance Fire Protection. The annual inspection is over due and no quarterly inspections had been performed.

Interview with the maintenance supervisor revealed the facility was not aware that the annual and the quarterly inspections had not been conducted on the automatic sprinkler system and this was also acknowledged by the Administrator during the exit meeting.

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 12 of 12 residents.
2 of 2 smoke compartments were deficient.

Findings:

During the facility tour, between the hours of 9:00AM to 3:30PM on 4/20/2017 and 1:00PM to 5:00PM on 4/21/2017 it was noted during record review that the plans show the corridor walls having a 1hour fire rating and continueing to the roof deck. It was observed that begining in the treatment/group room 1 through treatment/group room 2 on both sides of the corridors above the drop ceiling there are numerous gaps and penetrations in the walls.

Interview with the maintenance supervisor revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Based on visual observation the facility failed to assure that the elevators, for emergency personnel, are installed and tested as required by ASME/ANSI A17.3. The response time for responding rescue personnel could be delayed when the elevator equipment does not have the required programming. This deficiency could have the potential to affect 12 of 12 residents.

Findings:

During the facility tour and record review, between the hours of 9:00AM to 3:30PM on 4/20/2017 and 1:00PM to 5:00PM on 4/21/2017 it was observed that no documentation was provided for the elevators firefighter's service being operated monthly.


Interview with maintenance supervisor revealed the facility was not aware that the elevators firefighter's service was required to be operated monthly and a written record provided to ensure emergency personnel had access in emergency situations.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 12 of 12 residents.
1 of 4 quarters in 2016-2017 were deficient.

Findings:

During the record review, between the hours of 9:00AM to 3:30PM on 4/20/2017 and 1:00PM to 5:00PM on 4/21/2017 it was observed that no documentation was provided for the 2nd shift performing a fire drill during the 4th quarter of 2016.


Interview with maintenance supervisor revealed the facility was not aware fire drills were not held for the 2nd shift during the 4th quarter of 2016 and was verified by the Administrator during the exit interview.

Based on visual observation and record review the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110 and that the monthly testing program on the emergency generator was conducted and documented. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 12 of 12 residents.
12 of 12 months were deficient.

Findings:

During the facility tour and record review, between the hours of 9:00AM to 3:30PM on 4/20/2017 and 1:00PM to 5:00PM on 4/21/2017 it was observed that no remote manual stop for the generators had been provided. During the record review there was no documentation for weekly testing and the documentation for the monthly testing of the generator did not provide information of the generator being exercised under load for 30 minutes.

Interview with the maintenance director revealed the facility was not aware that a remote manual stop for emergency generators was required. Also the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator.