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Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting approximately 13 patients and any visitors and staff in 1 of 3 smoke zones. The facility has a capacity in the LTCU of 25 with a census of 24 and a capacity in the Hospital of 13 with a census of 7 at the time of the survey.

Findings include:

During the tour conducted on 03/24/16, it is observed:

-- 1. At approximately 12:30 p.m., it is discovered that the corridor door to Therapy Room has a thumb-turn lock and requires two motions to open for egress.

-- 2. At approximately 1:45 p.m., it is discovered that the corridor doors to the Kitchen have thumb-turn locks and require more than one motion to open for egress.

-- 3. At approximately 2:48 p.m., it is discovered that the corridor to the Pharmacy has two thumb-turn locks and an electronic lock, requiring more than one motion to open for egress.

Maintenance Director was present and acknowledged the findings.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99. This deficient practice fails to ensure the proper storage of combustible items, affecting approximately 23 residents and any visitors or staff in 1 of 3 smoke zones. The facility has a capacity in the LTCU of 25 with a census of 24 and a capacity in the Hospital of 13 with a census of 7 at the time of the survey.

During the tour conducted on 03/24/16, the following is observed:

-- 1. At approximately 11:15 a.m., it is discovered that there is an unsecured size " E " oxygen cylinder in Room 238.

The Maintenance Director was present and acknowledged the presence of an unsecured cylinder.

NFPA Standard: Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 2000 NFPA 101, 18.3.2.4

Based on record review 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 3 of 3 smoke zones. The facility has a capacity in the LTCU of 25 with a census of 24 and a capacity in the Hospital of 13 with a census of 7 at the time of the survey.

Findings include:

During the tour conducted on 03/24/16 at 12:20 p.m. it is observed that there is no remote shut-off provided for the automatic diesel generator.

Maintenance Director was present and acknowledged the lack of a remote shut-off for the automatic generator.

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.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all patients, residents and any staff or visitors in 3 of 3 smoke zones, including the Central Dining Room. The facility has a capacity in the LTCU of 25 with a census of 24 and a capacity in the Hospital of 13 with a census of 7 at the time of the survey.

During the tour conducted on 03/24/16, the following is observed:

-- 1. At approximately 11:15 a.m., it is discovered that there is a power strip suspended beside the television in room 238.

-- 2. At approximately 11:27 a.m. it is discovered that there is an open junction box on the back wall in the Med Room 224D.

-- 3. At approximately 2:45 p.m., 2:47 p.m. and 2:59 p.m., it is discovered that Patient Rooms 113 and 114 and Exam Room 118, respectively, have electrical outlets within 6 ' of a water source that are not protected with GFCI breakers.

The Maintenance Director was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.1.2

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.

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting approximately 13 patients and any visitors and staff in 1 of 3 smoke zones. The facility has a capacity in the LTCU of 25 with a census of 24 and a capacity in the Hospital of 13 with a census of 7 at the time of the survey.

Findings include:

During the tour conducted on 03/24/16, it is observed:

-- 1. At approximately 12:30 p.m., it is discovered that the corridor door to Therapy Room has a thumb-turn lock and requires two motions to open for egress.

-- 2. At approximately 1:45 p.m., it is discovered that the corridor doors to the Kitchen have thumb-turn locks and require more than one motion to open for egress.

-- 3. At approximately 2:48 p.m., it is discovered that the corridor to the Pharmacy has two thumb-turn locks and an electronic lock, requiring more than one motion to open for egress.

Maintenance Director was present and acknowledged the findings.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview, the facility failed to assure that medical gas storage is protected in accordance with NFPA 99. This deficient practice fails to ensure the proper storage of combustible items, affecting approximately 23 residents and any visitors or staff in 1 of 3 smoke zones. The facility has a capacity in the LTCU of 25 with a census of 24 and a capacity in the Hospital of 13 with a census of 7 at the time of the survey.

During the tour conducted on 03/24/16, the following is observed:

-- 1. At approximately 11:15 a.m., it is discovered that there is an unsecured size " E " oxygen cylinder in Room 238.

The Maintenance Director was present and acknowledged the presence of an unsecured cylinder.

NFPA Standard: Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 2000 NFPA 101, 18.3.2.4

Based on record review 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 3 of 3 smoke zones. The facility has a capacity in the LTCU of 25 with a census of 24 and a capacity in the Hospital of 13 with a census of 7 at the time of the survey.

Findings include:

During the tour conducted on 03/24/16 at 12:20 p.m. it is observed that there is no remote shut-off provided for the automatic diesel generator.

Maintenance Director was present and acknowledged the lack of a remote shut-off for the automatic generator.

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.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all patients, residents and any staff or visitors in 3 of 3 smoke zones, including the Central Dining Room. The facility has a capacity in the LTCU of 25 with a census of 24 and a capacity in the Hospital of 13 with a census of 7 at the time of the survey.

During the tour conducted on 03/24/16, the following is observed:

-- 1. At approximately 11:15 a.m., it is discovered that there is a power strip suspended beside the television in room 238.

-- 2. At approximately 11:27 a.m. it is discovered that there is an open junction box on the back wall in the Med Room 224D.

-- 3. At approximately 2:45 p.m., 2:47 p.m. and 2:59 p.m., it is discovered that Patient Rooms 113 and 114 and Exam Room 118, respectively, have electrical outlets within 6 ' of a water source that are not protected with GFCI breakers.

The Maintenance Director was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.1.2

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.