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Based on observation and staff interview, the facility does not provide a firewall with at least a two-hour fire resistance rating between the nursing home and hospital portion of the facility. A communicating opening compromises the fire-resistance rating of the designated firewall, increasing the risk of fire and smoke to the occupants. The deficient practice affects all patients, staff and visitors in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.

Findings include:

During the tour conducted on 07/21/15:

-- 1. At 2:00 p.m., it is observed that the facility has a door in a 2-hr wall separation between the hospital and the LTCU dining area that is not in connecting corridors. The 1 1/2 hour rated door has an automatic closing device and supervised smoke detection is located within the area.

Maintenance Supervisor and Director of Facilities were present and acknowledged the existence of a door in the 2-hr wall separation and not in connecting corridors.

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire-resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all patients, visitors and staff in 3 of 3 smoke zones. The facility has a capacity 25 of with a census of 2 at the time of the survey.

Findings include:

During the tour conducted on 07/20/2015, between 1:30 p.m. and 3:00 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. No drills conducted for the 2nd Shift 2nd Qtr. 2014, 1st or 2nd Shift 3rd Qtr. 2014, 1st or 2nd Shift 4th Qtr. 2014 or 2nd Shift 2nd Qtr. 2015.

Maintenance Supervisor and Director of Facilities were present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview, the facility fails to maintain and test the emergency generator as per NFPA 110. This deficient practice could result in failure of the generator to provide emergency power in the event of power loss. The deficient practice could affect all occupants and all residents in 3 of 3 smoke zones. The facility has a capacity of 25 and a census of 2 at the time of the survey.

Findings include:

During the tour conducted on 07/20/15, between 1:30 p.m. 3:00 p.m., during a review of records for the last five quarters, it is observed:

-- 1. The generator is run weekly for a period of 30 minutes. Documentation reflects that the generator is exercised under load conditions for only 6 minutes per month.

The Maintenance Supervisor and Director of Facilities were present and acknowledged the results of the records review. Both Maintainenance Supervisor and Director of Facilities stated that the 25KW generator is a convenience generator only and provides power for supplemental lighting in addition to the battery back-up emergency lights and office computers. Patients are never placed on life support.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

NFPA Standard: Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be decided by the owner, based on facility operations. 1999 NFPA 110, 6-4.2

NFPA Standard: Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. 1999 NFPA 110, 6-4.2.2

Based upon observation and staff interview, the facility fails to assure that electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. The deficient practice could result in an electrical short causing a fire, affecting approximately 10 patients and any visitors and staff in 2 of 3 smoke zones. The facility has a capacity of 25 and a census of 2 at the time of the survey.

Findings include:

During the tour conducted on 07/21/15 it is observed:

-- 1. At 3:05 p.m., in the Acute Care kitchenette, there is an electrical outlet within 6' of a hand sink that does not have Ground-Fault Circuit-Interrupter (GFCI) protection.

-- 2. At 3:43 p.m., in the Clean Room, there is an electrical outlet within 6' of a hand sink that does not have Ground-Fault Circuit-Interrupter (GFCI) protection.

Maintenance Supervisor and Director of Facilities were present and acknowledged the findings.

NFPA Standard: All 125-volt, single-phase, 15- and 20-ampere receptacles installed in bathrooms, garages, storage areas, work areas, and area of similar use shall have Ground-Fault Circuit-Interrupter (GFCI) protection. 1999 NFPA 70, 210-8.