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Based on observation and interview, the facility failed to maintain the smoke barriers free of penetrations. The deficient practice would allow smoke and fire to spread to the adjoining smoke compartment which would affect 3 patients. Facility census was 3 patients.

Findings are:

Observations on 11/30/2016 at1:49 P.M. revealed the smoke barrier wall above the ceiling by Room 101 was concrete block construction and had penetrations through the wall for plumbing and air duct that were not sealed.

During an interview on 11/30/2016 at 1:49 P.M. Maintenance A indicated that they were unaware that the penetration had not been sealed when the pipes and duct had been added.

Based on record review and interview, the facility failed to conduct fire drills under varied conditions for 1 of 4 quarters reviewed. The deficient practice did not challenge staff to respond to fire emergencies during various times and staffing levels, and had the potential to affect staff preparation and experience to provide for the protection of all patients in the event of a fire. The facility had a census of 3 at the time of survey.

Findings are:

Record review on 11/30/16, at 3:45 P.M., of the facility fire drill documentation for the year 2016 and 2015, revealed the facility did not have documentation for a drill for the second shift for the second quarter of 2016.

During interview on 11/30/16 at 3:45 P.M. Maintenance A acknowledged the lack of documentation.

Based on observation and interview, the facility failed to restrict the use of extension cords and failed to follow precautions for the use of relocatable power taps. This deficient practice increased the potential to overload the circuit and cause an electrical fire, which would affect 3 residents. Facility census was 3 residents.

Findings are:
Observations on 11/30/2016 at 1:56 P.M. revealed a relocatable power tap was being used to provide power for power for a coffee pot and refrigerator in the nurses' report room.

During an interview on 11/30/2016 at 1:56 P.M. Maintenance A indicated that they were unaware of the use of the power tap.

Observations on 11/30/2016 2:30 P.M. revealed an extension cord was being used to provide power for the microwave in the dining room.

During an interview on 11/30/2016 at 2:30 P.M. Maintenance A indicated that they did not know the extension cord was used for the microwave and removed it from use.