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Based upon record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents, visitors and staff in 1 of 1 smoke zones. The facility has a capacity of 10 with a census of 4 at the time of this survey.

Findings include:

During the tour conducted on 12/14/17, a review of records for the last 5 quarters between 11:30 a.m. and 1:00 p.m., revealed the following:

-- 1. No documented drill for the 2nd Shift, 1st Qtr. 2017.

Chief Executive Officer and VP Support Services were present and acknowledged the results of the records review.

NFPA Standard: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff (nurses, interns, maintenance engineers, and administrative staff) is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

Based upon observation and staff interview, the facility fails to provide a remote shut-off for the generator. This deficient practice 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 12 with a census of 10.

Findings include:

During the tour conducted on 12/14/17, at 5:12 p.m., it is observed that there is no remote emergency shut-off provided for the automatic diesel generator.

Chief Executive Officer and VP Support Services were present and acknowledged the observation.

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.