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Based on observation and interview the facility failed to provide an even, all-weather surface from each exit to a public way (an area of safety). This deficient practice affects all patients in 2 of 2 patient room corridors which exit on the southwest side of the facility that might require the use of a flat, solid, clean surface to escape the facility in an emergency. The facility census was 7.

Findings included:

1. Observation on 02/15/17 at 10:45 AM during a tour of the facility showed only a small concrete pad at the exit discharge doors to the outside from both patient room corridors which would require patients to travel over an uneven, grass surface to reach an area of safety.

2. Staff I, Maintenance Supervisor, confirmed at that time an even, all-weather surface from both exits to an area of safety had not been provided.

Section 7.7.1 of the National Fire Protection Association (NFPA 101) states: Exits shall terminate directly, at a public way or at an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.

Based on record review and interview the facility failed to conduct a semi-annual inspection of the range hood suppression system in the kitchen. This deficient practice affects all occupants in the facility. The facility census was 7.

Findings included:

1. Review of the facility kitchen range hood suppression system documents, conducted on the afternoon of 02/14/17, showed an outside contractor had last conducted an inspection of the range hood suppression system in April of 2016. There was no documentation showing any inspection of the suppression system being conducted since April of 2016.

2. During an interview on 02/16/17 at 9:05 AM, Staff I, Maintenance Supervisor, stated there was no documentation to show an inspection of the range hood suppression system had been conducted since April of 2016.

Section 19.3.2.5.3 (5) (a) of the National Fire Protection Association (NFPA 101) states: The cooktop or range is protected with a fire suppression system listed in accordance with UL 300, or is tested and meets all requirements of UL 300A in accordance with the applicable testing document's scope.

Based on record review and interview the facility failed to conduct fire drills at least quarterly for each shift. This deficient practice has the potential to affect all occupants in the facility. The facility census was 7.

Findings included:

1. Review of the fire drill records for 2016, conducted on the afternoon of 02/15/17, showed the following:
-The last fire drill conducted for the 1st quarter, January through March, of 2016 occurred on 02/01/16 with the next documented drill occurring during the 3rd quarter, July through September, on July 29, 2016.
-There was no documentation showing a fire drill was conducted during the 2nd quarter, April through June, of 2016.

2. During an interview on 02/16/17 at 9:03 AM, Staff I, Maintenance Supervisor, stated there was no documentation showing fire drills had been conducted during April through June of 2016.

Section 19.7.1.6 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Based on record review and interview the facility failed to develop a maintenance program for the medical gas, vacuum, WAGD (Waste Anesthetic Gas Disposal), or support gas system within the facility . This deficient practice affects all patients in the facility. The facility census was 7.

Findings included:

1. Review of the facility maintenance program documentation, conducted on the afternoon of 02/15/17, showed the facility did not have a program in place which includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets, and an inspection and maintenance schedule for this system.

2. During an interview on 02/16/17 at 9:01 AM, Staff I, Maintenance Supervisor, stated a maintenance program for this system had not been developed.

Section 5.1.14.2.2.1 of the National Fire Protection Association (NFPA 99) states: Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

Based on record review and interview the facility failed to develop a program for the evaluations of hazards and fire prevention procedures for the operating room. This deficient practice affects all patients and staff in the operating room. The facility census was 7.

Findings included:

1. Review of the facility fire safety documents, conducted on the afternoon of 02/15/17, showed the facility did not have a program in place for the periodic evaluations of hazards in the operating room and fire prevention procedures have not been established.

2. During an interview on 02/16/17 at 9:02 AM, Staff I, Maintenance Supervisor, stated a program for the hazards evaluations and fire prevention procedures had not been established.

Section 15.13.3.9.1 of the National Fire Protection Association (NFPA 99) states: Procedures for operating room/surgical suite emergencies shall be developed.