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Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice affects all occupants, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 03/10/15 at 9:11 a.m., revealed the facility failed to conduct a fire drill during the night shift of the third quarter for 2014. The Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to conduct the required bi-annual sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) 72. This deficient practice affects all occupants as this lack of testing would not ensure that the sensitivity of the detectors were within the manufacturer's specification. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 03/10/15 at 9:24 a.m., revealed smoke detector sensitivity testing had not been conducted since July of 2012. The Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. Three of thirty-three fire extinguishers in the facility were affected by this deficient practice. This deficient practice would affect 8 residents, staff, and visitors. The facility has a capacity of 25 and a census of 4.

Findings include:

1. Observation and interview on 03/10/15 at 10:16 a.m., revealed the facility failed to conduct monthly inspections of the fire extinguisher in the Old Boiler Room. The extinguisher tag had no dates or initials for the month's of January and February 2015.

2. Observation and interview on 03/10/15 at 10:36 a.m., revealed the facility failed to conduct monthly inspections of the K type fire extinguisher in the Kitchen. The extinguisher tag had no dates or initials for the month's of October 2014-February 2015.

3. Observation and interview on 03/10/15 at 10:57 a.m., revealed the facility failed to conduct monthly inspections of the fire extinguisher in the Operating Room. The extinguisher tag had no dates or initials for the month's of November 2014-February 2015. The Maintenance Staff verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to provide proper inspection and documentation of the building's emergency generator. This deficient practice would affect all residents, staff, and visitors throughout the facility. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 03/10/15 at 11:15 a.m., revealed the facility could not provide documentation for weekly visual inspections of the emergency generator for the 2nd week of April 2014, the 2nd and 3rd weeks of May 2014, the 3rd week of July 2014, the 2nd week of September 2014, the 2nd week of November 2014, the 3rd week of December 2014, the 1st week of January 2015, and the 2nd week of February 2015. The Maintenance Staff verified these observations at the time of the survey process.

Based on observation and interview, 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. This deficient practice affects one of three smoke zones and 4 staff. This facility had a capacity of 25 and a census of 4.

Findings Include:

1. Observation and interview on 03/10/15 at 10:41 a.m., revealed the facility failed to maintain the electrical system in the Rehabilitation Office. This room contained a white six way electrical adaptor plugged into an outlet along the East wall.

2. Observation and interview on 03/10/15 at 10:53 a.m., revealed the facility failed to maintain the electrical system in the Pharmacy. This room contained a 1/2" flexible conduit with an outlet that was not securely mounted to the wall. The Maintenance Staff verified these observations at the time of the survey process.

Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice affects all occupants, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 03/10/15 at 9:11 a.m., revealed the facility failed to conduct a fire drill during the night shift of the third quarter for 2014. The Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to conduct the required bi-annual sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) 72. This deficient practice affects all occupants as this lack of testing would not ensure that the sensitivity of the detectors were within the manufacturer's specification. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 03/10/15 at 9:24 a.m., revealed smoke detector sensitivity testing had not been conducted since July of 2012. The Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. Three of thirty-three fire extinguishers in the facility were affected by this deficient practice. This deficient practice would affect 8 residents, staff, and visitors. The facility has a capacity of 25 and a census of 4.

Findings include:

1. Observation and interview on 03/10/15 at 10:16 a.m., revealed the facility failed to conduct monthly inspections of the fire extinguisher in the Old Boiler Room. The extinguisher tag had no dates or initials for the month's of January and February 2015.

2. Observation and interview on 03/10/15 at 10:36 a.m., revealed the facility failed to conduct monthly inspections of the K type fire extinguisher in the Kitchen. The extinguisher tag had no dates or initials for the month's of October 2014-February 2015.

3. Observation and interview on 03/10/15 at 10:57 a.m., revealed the facility failed to conduct monthly inspections of the fire extinguisher in the Operating Room. The extinguisher tag had no dates or initials for the month's of November 2014-February 2015. The Maintenance Staff verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to provide proper inspection and documentation of the building's emergency generator. This deficient practice would affect all residents, staff, and visitors throughout the facility. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 03/10/15 at 11:15 a.m., revealed the facility could not provide documentation for weekly visual inspections of the emergency generator for the 2nd week of April 2014, the 2nd and 3rd weeks of May 2014, the 3rd week of July 2014, the 2nd week of September 2014, the 2nd week of November 2014, the 3rd week of December 2014, the 1st week of January 2015, and the 2nd week of February 2015. The Maintenance Staff verified these observations at the time of the survey process.

Based on observation and interview, 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. This deficient practice affects one of three smoke zones and 4 staff. This facility had a capacity of 25 and a census of 4.

Findings Include:

1. Observation and interview on 03/10/15 at 10:41 a.m., revealed the facility failed to maintain the electrical system in the Rehabilitation Office. This room contained a white six way electrical adaptor plugged into an outlet along the East wall.

2. Observation and interview on 03/10/15 at 10:53 a.m., revealed the facility failed to maintain the electrical system in the Pharmacy. This room contained a 1/2" flexible conduit with an outlet that was not securely mounted to the wall. The Maintenance Staff verified these observations at the time of the survey process.