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Based on observation and interview, the facility is not assuring that stairway exit inclosure are provided with doors that close and positive latch with-in the door frame. This deficient practice could potentially affecting six residents, visitors and staff in the event of an emergency. This facility has a capacity of 18 with a census of 4 residents.

Findings include:

Observation and interview on 10-18-16 at approximately 11:10 a.m., revealed the 2nd floor north stairway tower door failed to close and positive latch with-in the door frame.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility did not provide a directional exit signs at the end of a resident corridor for one of three zones. This deficient practice effects all residents, staff and visitors in this facility with a capacity of 18. The facility had a census of 4 residents.

Findings include:

Observation and interview on 10-18-16 at approximately 9:45 a.m., revealed the exit corridor in the Specialty Clinic Hall did not have an exit sign at the east end of the corridor to indicate the direction of the exit travel.


According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Maintenance Staff (A) verified this observation.

(A)
Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 18 with a census of 4.

Findings include:

Observation and interview on 10-18-16, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the Air Handling room electrical panel LLB 01 breaker #4 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff (A) verified this observation.

(B)
Based on observation and interview, the facility failed to provide a properly maintained fire alarm system. The deficient practice of failing to verify that the Main Fire Alarm Panel communicates the alarm signal to the monitoring company would affect all of the building occupants. This facility has a capacity of 18 and a census of 4 residents.

Findings include:

Observation and interview on 10-17-16 revealed, that during the testing of the fire alarm system during fire drills, the facility was not verifying that the monitoring company was receiving the alarm signal.

Maintenance Staff (A) verified this observation.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 18 and a census of 4 at the time of the survey.

Findings Include:

1. Observation and interview on 10-18-16 at 10:20 a.m., revealed the facility failed to maintain the electrical system in the Pre Post Surgical corridor. In Panel CLB15 the following breakers: 9, 10, 14 and 15 were in the on position, charged and labeled as spares.

2. Observation and interview on 10-18-16 at 10:20 a.m., revealed the facility failed to maintain the electrical system in the Pre Post Surgical corridor. In Panel NLB15 the following breakers: 15, 21, 38 and 40, were in the on position, charged and labeled as spares.

3. Observation and interview on 10-18-16 at 10:20 a.m., revealed the facility failed to maintain the electrical system in the Pre Post Surgical corridor. In Panel NLB16 the following breakers: 32 and 34 were in the on position, charged and labeled as spares.

4. Observation and interview on 10-18-16 at 10:39 a.m., revealed the facility failed to maintain the electrical system in the Therapy room. In Panel NLB03 the three breakers were not labeled to signify their designations.

5. Observation and interview on 10-18-16 at 10:40 a.m., revealed the facility failed to maintain the electrical system in the Air Handling room. In Panel NLB01 the following breakers: 38 and 40, were in the on position, charged and labeled as spares.

6. Observation and interview on 10-18-16 at 10:40 a.m., revealed the facility failed to maintain the electrical system in the Air Handling room. In Panel CLB01 the following breakers: 36, 37 and 38 were in the on position, charged and labeled as spares.

7. Observation and interview on 10-18-16 at 11:00 a.m., revealed the facility failed to maintain the electrical system in the Medical Surgical. In Panel NLB25 the following breakers: 28, 29, 30, 31, 32, 33, and 34 were in the on position, charged and labeled as spares.

8. Observation and interview on 10-18-16 at 11:08 a.m., revealed the facility failed to maintain the electrical system in the Medical Surgical. In Panel CLB21 the breakers were not labeled to signify their designations.

9. Observation and interview on 10-18-16 at 10:40 a.m., revealed the facility failed to maintain the electrical system in the Therapy room. On the west wall of the Therapy room there was a green electrical extension cord use for holiday decoration. Maintenance Staff (B) removed the cord at the time of the survey.

Maintenance Staff (A) and (B) verified these observations.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 18 and a census of 4 at the time of the survey.

Findings Include:

Observation and interview on 10-18-16 at 10:04 a.m., revealed the facility failed to maintain the electrical system in the Specialty Clinic corridor. In the electrical panel NLBE2 the following breakers: 3, 7, 26, 28, 30, 32, 34, 36, 40 and 42 were in the on position, charged and labeled as spares.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility is not assuring that stairway exit inclosure are provided with doors that close and positive latch with-in the door frame. This deficient practice could potentially affecting six residents, visitors and staff in the event of an emergency. This facility has a capacity of 18 with a census of 4 residents.

Findings include:

Observation and interview on 10-18-16 at approximately 11:10 a.m., revealed the 2nd floor north stairway tower door failed to close and positive latch with-in the door frame.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility did not provide a directional exit signs at the end of a resident corridor for one of three zones. This deficient practice effects all residents, staff and visitors in this facility with a capacity of 18. The facility had a census of 4 residents.

Findings include:

Observation and interview on 10-18-16 at approximately 9:45 a.m., revealed the exit corridor in the Specialty Clinic Hall did not have an exit sign at the east end of the corridor to indicate the direction of the exit travel.


According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Maintenance Staff (A) verified this observation.

Based upon record review and interview, the facility failed to hold fire drills under varied times of the months for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 18 with a census of 4.

Findings include:

Record review on 10-17-16, the facility fire drill documentation showed that fire drills for all four quarters and shifts were conducted at approximately the same day. The drills were conducted as follows: in the first quarter the drills were conducted on 2-13-16 at 9:45 a.m. on 9-14-16 at 9:15 a.m. on 3-30-16 at 2:00 p.m. on 4-29-16 at 2:00 p.m. on 7-29-16 at 2:00 p.m. on 10-30-15 at 4:30 p.m. on 11-30-15 at 4:30 p.m. and on 12-31-15 at 4:30 p.m. The facility also failed to conduct fire drills for the second shift in the first quarter of the 2016 year and for the second shift in the forth quarter of the 2015 year.


Maintenance Staff (A) verified the documentation.

(A)
Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 18 with a census of 4.

Findings include:

Observation and interview on 10-18-16, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the Air Handling room electrical panel LLB 01 breaker #4 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff (A) verified this observation.

(B)
Based on observation and interview, the facility failed to provide a properly maintained fire alarm system. The deficient practice of failing to verify that the Main Fire Alarm Panel communicates the alarm signal to the monitoring company would affect all of the building occupants. This facility has a capacity of 18 and a census of 4 residents.

Findings include:

Observation and interview on 10-17-16 revealed, that during the testing of the fire alarm system during fire drills, the facility was not verifying that the monitoring company was receiving the alarm signal.

Maintenance Staff (A) verified this observation.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 18 and a census of 4 at the time of the survey.

Findings Include:

1. Observation and interview on 10-18-16 at 10:20 a.m., revealed the facility failed to maintain the electrical system in the Pre Post Surgical corridor. In Panel CLB15 the following breakers: 9, 10, 14 and 15 were in the on position, charged and labeled as spares.

2. Observation and interview on 10-18-16 at 10:20 a.m., revealed the facility failed to maintain the electrical system in the Pre Post Surgical corridor. In Panel NLB15 the following breakers: 15, 21, 38 and 40, were in the on position, charged and labeled as spares.

3. Observation and interview on 10-18-16 at 10:20 a.m., revealed the facility failed to maintain the electrical system in the Pre Post Surgical corridor. In Panel NLB16 the following breakers: 32 and 34 were in the on position, charged and labeled as spares.

4. Observation and interview on 10-18-16 at 10:39 a.m., revealed the facility failed to maintain the electrical system in the Therapy room. In Panel NLB03 the three breakers were not labeled to signify their designations.

5. Observation and interview on 10-18-16 at 10:40 a.m., revealed the facility failed to maintain the electrical system in the Air Handling room. In Panel NLB01 the following breakers: 38 and 40, were in the on position, charged and labeled as spares.

6. Observation and interview on 10-18-16 at 10:40 a.m., revealed the facility failed to maintain the electrical system in the Air Handling room. In Panel CLB01 the following breakers: 36, 37 and 38 were in the on position, charged and labeled as spares.

7. Observation and interview on 10-18-16 at 11:00 a.m., revealed the facility failed to maintain the electrical system in the Medical Surgical. In Panel NLB25 the following breakers: 28, 29, 30, 31, 32, 33, and 34 were in the on position, charged and labeled as spares.

8. Observation and interview on 10-18-16 at 11:08 a.m., revealed the facility failed to maintain the electrical system in the Medical Surgical. In Panel CLB21 the breakers were not labeled to signify their designations.

9. Observation and interview on 10-18-16 at 10:40 a.m., revealed the facility failed to maintain the electrical system in the Therapy room. On the west wall of the Therapy room there was a green electrical extension cord use for holiday decoration. Maintenance Staff (B) removed the cord at the time of the survey.

Maintenance Staff (A) and (B) verified these observations.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 18 and a census of 4 at the time of the survey.

Findings Include:

Observation and interview on 10-18-16 at 10:04 a.m., revealed the facility failed to maintain the electrical system in the Specialty Clinic corridor. In the electrical panel NLBE2 the following breakers: 3, 7, 26, 28, 30, 32, 34, 36, 40 and 42 were in the on position, charged and labeled as spares.

Maintenance Staff (A) verified this observation.