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Based on observation and interview, the facility failed to maintain the emergency egress lighting system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by not ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. This deficient practice affects all of the outside light fixtures in the facility and all residents and staff. The facility has a capacity of 21 and a census of 6.

Findings include:

1. Observation, document review and interview on 5-29-19 at 10:00 a.m., revealed the battery backup emergency lighting located in the facility were not listed for their locations. the facility produced documentation via P.M. work orders but this documentation did not indicate how many lights or their locations.

2. Observation, document review and interview on 5-31-19 at 9:44 a.m., revealed the battery backup emergency lighting located in the waiting room of the 322 1/2 College Avenue Clinic failed function when tested on site.

Maintenance Staff A verified these observations time of the survey process.

Based on record review and interview, the facility failed to maintain the inspection and servicing schedule of the commercial cooking exhaust system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.2.3 and NFPA Standard 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 11.2. This deficient practice affects one of six smoke zones and could affect all residents, staff, and visitors in the Dining Room. The facility had a capacity of 21 and a census of 6 at the time of the survey.

Findings include:

Record review on 5-29-19 at 11:30 a.m. of the facility's cooking operations documentation, revealed the facility failed to maintain the Kitchen hood exhaust system. The facility failed to have the grease exhaust removal system cleaned by a certified company semi annually. Interview of the Maintenance Supervisor revealed they were having the hood cleaned annually. They also stated they were unaware the inspection interval was not to exceed six months.

The Maintenance Supervisor verified the documentation during the survey.

Based on observation and interview, the facility failed to maintain the fire alarm system within the building in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code and Signaling Code, 2010 edition. This deficient practice could affect all occupants within the facility. The facility had a capacity of 21 and a census of 6 residents at the time of the survey.

Findings include:

Observation and interview on 5-31-19 at 11:29 a.m., revealed the facility failed to maintain the fire alarm system in the Ackley Clinic. The batteries in the Main Fire Alarm Panel were dated 10-2012. Fire alarm batteries are required to be replaced every 5 years. The Maintenance Supervisor confirmed this observation at the time of the survey.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with NFPA 25, by ensuring sprinklers were replaced if corroded. This deficient practice of failing to provide prompt correction of deficiencies did not ensure proper operation and prompt repair of the system. This affected approximately 40 occupants in this facility with a capacity of 21 and a census of 6 residents at the time of the survey.

Findings include:

1. Record review and interview on 5-29-19 at approximately 12:15 p.m., revealed the sprinkler head in the Diabetic Closet was obstructed by storage approximately 6 inches from the sprinkler head diffuser. This deficient practice was confirmed by Maintenance Staff A at the times of discovery.


2. Record review and interview on 5-29-19 at approximately 11:52 a.m., revealed the ceiling mounted sprinkler head in the O.R. Nurses Station was covered with dust. This deficient practice was confirmed by Maintenance Staff A at the times of discovery.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, 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 21 residents with a census of 6.

Findings include:

1. Record review and interview on 5-29-19 between 9:30 and 10:00 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct a fire drill during the second shift for the first quarter of 2019. The facility also failed to conduct a fire drill for the second shift in the forth quarter in the 2018 year. Maintenance Staff A verified the documentation during the survey process.

2. Record review and interview on 5-29-19 at 9:30 a.m. of the facility's fire drill documentation, revealed the second shift drills were conducted at approximately the same time of day. The drills were conducted as follows: on 6-22-18 at 2:55 p.m. on 9-13-18 at 2:40 p.m. on 11-29-18 at 1:27 p.m. and on 12-20-18 at 1:51 p.m.

The Maintenance Director verified the documentation during the survey process.

Based on record review and interview, (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3 and 8.4.2 The deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 21 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 5-29-19 at 10:00 a.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator diesel fuel.

Maintenance Staff A confirmed this observation at the time of the survey.

Based on observation, interview and record review the facility is not storing oxygen tanks in accordance with NFPA 99, by ensuring that the Oxygen room was properly placard. This deficient practice occurred in one oxygen storage room and affected approximately 6 occupants. This facility had a capacity of 21 and a census of 6 residents at the time of the survey.

Findings include:

Observation and interview on 5-29-19 at 11:55 a.m., revealed the Oxygen Storage Room in the Northwest Wing was not properly placarded.

This deficient practice was confirmed by Maintenance Staff A at the time of discovery.