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Based on observation and interview, the facility failed to maintain corridors free of obstructions in 1 of 6 smoke compartments (Zone 2). This deficient practice could delay evacuation of staff from the basement during an emergency. The deficient practice affected 0 residents. This facility had a capacity of 17 and a census of 3 residents at the time of the survey.

Findings are:

Observations on 9-27-17, at 2:48 pm revealed the physical therapy stair prop was stored in the exit corridor for the basement. The corridor width was 5'6" wide.

During an interview on 9-27-17 at 2:48 pm, Maintenance Staff A confirmed the stair prop in the corridor was not in use and being stored.

Based on observation and interview the facility failed to install the pull station for the fire suppression system for the kitchen hood at a height that was between 42 and 48 inches above the floor in 1 of 6 smoke compartments (Zone 3). This condition could prevent staff from accessing and operating the kitchen hood fire suppression system, which would allow a fire on the stove to increase in size. The deficient practice affected 0 residents. This facility had a capacity of 17 and a census of 3 residents at the time of the survey.

Findings are:

Observations on 9-27-17 at 2:27 pm revealed, the kitchen hood fire suppression system manual pull station measured 66 inches off of the floor.

During an interview on 9-27-17 at 2:27 pm, Maintenance Staff A confirmed the measurement.

NFPA 96 10.5.1 A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected.

Based on documentation review and staff interview, the facility failed to hold fire drills under varied conditions on 2 of 2 shifts for the 4 quarters reviewed, by not conducting the fire drills at least one hour apart from all other drills on the shift. This condition did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response for all residents. The deficient practice would affect all residents. The facility census was 3.

Findings are:

Fire drill documentation review on 9-27-17 at 11:46 am revealed:

1. First shift fire drills were conducted at 1:20 pm on 10-31-16, 12:45 pm on 12-21-16, 8:30 am on 2-20-17, 9:15 on 3-30-17, 5:30 pm on 4-13-17, 11:00 am on 5-31-17, 1:15 pm on 6-26-17, 2:11 pm on 7-20-17, 11:22 am on 8-28-17.

2. Second shift fire drills were conducted at 6:00 am on 10-31-16, 6:07 am on 12-22-16, 3:00 am on 2-21-17, 7:00 am on 4-14-17, 7:00 am on 5-31-17, 6:05 am on 6-27-17, 11:06 pm on 7-19-17, 6:30 am on 8-30-17.

During an interview on 9-27-17 at 11:46 am, Maintenance Staff A confirmed the drills failed to be conducted under varied conditions.

Based on observation and staff interview, the facility allowed the use of a power strip cord in lieu of permanent wiring in 1 of 6 smoke compartments (Zone 5). The deficient practice increased the potential for a fire caused by failure of the power strip. The deficient practice affected 0 residents. This facility had a capacity of 17 and a census of 3 residents at the time of the survey.

Findings are:

Observation on 9-27-17, at 1:26 pm, revealed the blood bank refrigerator was plugged into a power strip in the Lab rather than directly into the electrical receptacle.

During an interview on 9-27-17, at 1:26 pm. Maintenance Staff A confirmed the use of the electrical power strip on the refrigerator.

Based on observation and staff interview, the facility failed to label oxygen cylinders as full or empty and failed to segregate full cylinders form empty ones. The deficient practice could cause confusion when choosing tanks in an emergency resulting in an empty cylinder being chosen when a full one was required. The deficient practice affected 3 residents. This facility had a capacity of 17 and a census of 3 residents at the time of the survey. (Zone 2)

Findings are:

Observation on 9-27-17, at 2:19 pm, revealed the oxygen storage room contained multiple size "E" oxygen cylinders that were not labeled as being full or empty and the empty cylinders were not physically separated from the full ones.

During an interview on 9-27-17, at 2:19 pm, Maintenance Staff A confirmed the findings.