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Based on observation and staff interview, the facility fails to test the battery powered emergency lighting annually as required by NFPA 101 7.9.3 This deficient practice would not assure that areas are properly illuminated in the event of an emergency, affecting all residents, staff and visitors in 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015, at approximately 4:00 p.m., a review of records for the last 5 quarters revealed:

-- 1. No documented 90-minute annual testing of the emergency lighting units within the last 12 months.

-- 2. Computerized records note that monthly 30-second functional tests as a whole were completed on various dates. Unable to determine which specific units were tested or the results of each test.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged the results of the records review.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all residents, visitors and staff in 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015, between at approximately 2:25 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. No documented drill for the 2nd Shift, 2nd quarter of 2015.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based upon a review of records, observation and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all residents, staff and visitors in 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015, a review of records for the last five quarters revealed the following:

-- 1. At approximately 2:00 p.m., annual sprinkler report dated 05/28/2015 notes: "the 2" main drain did not want to shut off all the way; 1 dry pendant in hospital to replace and 1 dry pendant in freezer to replace".

-- 2. At approximately 2:10 p.m., no documented quarterly flow test for the 1st quarter of 2015.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged the results of the records review.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation, record review and staff interview, the facility failed to assure that fire dampers are tested and maintained in accordance with UL 555C, Standard for Safety Ceiling Dampers. 1999 NFPA 90A, 3-4.4. The deficient practice could result in a hazardous condition due to improper installation or operation, affecting all residents and any staff and visitors in 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings Include:

During the tour conducted on 09/17/2015 at approximately 3:33 p.m., during a review of records, it is revealed that the facility has fire dampers and has no record of testing or maintaining the dampers.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged that the dampers have not been tested.

NFPA Standard: Ceiling dampers or other methods of protecting openings in rated floor- or roof-ceiling assemblies shall comply with the construction details of the tested floor- or roof-ceiling assembly or with listed ceiling air diffusers or listed ceiling dampers. Ceiling dampers shall be tested in accordance with UL 555C, Standard for Safety Ceiling Dampers. 1999 NFPA 90A, 3-4.4

NFPA Standard: At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. 1999 NFPA 90A, 3-4.7

Based on record review and staff interview, the facility fails to assure that generators are tested and maintained in accordance with the requirements of NFPA 110 and fails to provide a remote shut-off for the generator. The deficient practices could result in 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 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015 at 3:30 p.m., it is observed that there is no remote shut-off provided for the automatic generator.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged that there is no remote emergency shut-off for the generator.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

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 upon observation and staff interview, the facility fails to assure that electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. The deficient practice could result in an electrical short causing a fire, affecting no residents or patients and any staff or visitors in 2 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015, it is observed:

-- 1. At 3:01 p.m., in the Laundry, a power-strip was plugged into another power-strip.

-- 2. At 4:15 p.m., in the room identified as Freight Room, it is observed that there is an electrical outlet within 6' of a hand sink that does not have Ground-Fault Circuit-Interrupter (GFCI) protection.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged the unprotected outlet.

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 test the battery powered emergency lighting annually as required by NFPA 101 7.9.3 This deficient practice would not assure that areas are properly illuminated in the event of an emergency, affecting all residents, staff and visitors in 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015, at approximately 4:00 p.m., a review of records for the last 5 quarters revealed:

-- 1. No documented 90-minute annual testing of the emergency lighting units within the last 12 months.

-- 2. Computerized records note that monthly 30-second functional tests as a whole were completed on various dates. Unable to determine which specific units were tested or the results of each test.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged the results of the records review.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all residents, visitors and staff in 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015, between at approximately 2:25 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. No documented drill for the 2nd Shift, 2nd quarter of 2015.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based upon a review of records, observation and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic fire sprinkler system, affecting all residents, staff and visitors in 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015, a review of records for the last five quarters revealed the following:

-- 1. At approximately 2:00 p.m., annual sprinkler report dated 05/28/2015 notes: "the 2" main drain did not want to shut off all the way; 1 dry pendant in hospital to replace and 1 dry pendant in freezer to replace".

-- 2. At approximately 2:10 p.m., no documented quarterly flow test for the 1st quarter of 2015.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged the results of the records review.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation, record review and staff interview, the facility failed to assure that fire dampers are tested and maintained in accordance with UL 555C, Standard for Safety Ceiling Dampers. 1999 NFPA 90A, 3-4.4. The deficient practice could result in a hazardous condition due to improper installation or operation, affecting all residents and any staff and visitors in 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings Include:

During the tour conducted on 09/17/2015 at approximately 3:33 p.m., during a review of records, it is revealed that the facility has fire dampers and has no record of testing or maintaining the dampers.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged that the dampers have not been tested.

NFPA Standard: Ceiling dampers or other methods of protecting openings in rated floor- or roof-ceiling assemblies shall comply with the construction details of the tested floor- or roof-ceiling assembly or with listed ceiling air diffusers or listed ceiling dampers. Ceiling dampers shall be tested in accordance with UL 555C, Standard for Safety Ceiling Dampers. 1999 NFPA 90A, 3-4.4

NFPA Standard: At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. 1999 NFPA 90A, 3-4.7

Based on record review and staff interview, the facility fails to assure that generators are tested and maintained in accordance with the requirements of NFPA 110 and fails to provide a remote shut-off for the generator. The deficient practices could result in 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 8 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015 at 3:30 p.m., it is observed that there is no remote shut-off provided for the automatic generator.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged that there is no remote emergency shut-off for the generator.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

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 upon observation and staff interview, the facility fails to assure that electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. The deficient practice could result in an electrical short causing a fire, affecting no residents or patients and any staff or visitors in 2 of 8 smoke zones. The facility has a capacity in the Hospital of 24 with a census of 6 and a capacity in the LTCU of 37 with a census of 12.

Findings include:

During the tour conducted on 09/17/2015, it is observed:

-- 1. At 3:01 p.m., in the Laundry, a power-strip was plugged into another power-strip.

-- 2. At 4:15 p.m., in the room identified as Freight Room, it is observed that there is an electrical outlet within 6' of a hand sink that does not have Ground-Fault Circuit-Interrupter (GFCI) protection.

Plant Operations Supervisor and Assistant Plant Operations Supervisor were present and acknowledged the unprotected outlet.

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.