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Based on observation and interview, the facility fails to provide emergency lighting of at least 1½-hour duration at the nurse ' s medication preparation area, as required by NFPA 99. The deficient practice would not provide illumination of the medication preparation area in the event of a loss of power, affecting no residents and any visitors or staff in 1 of 3 smoke zones. The facility has a capacity of 12 with a census of 0 at the time of this survey.

Findings include:

During the tour conducted on 04/13/2016, at approximately 3:12 p.m., the emergency lighting unit located in the medication preparation room failed to illuminate when tested.

Facilities Director was present and acknowledged the findings.


NFPA Standard: Task illumination required at medication preparation areas. 1999 NFPA 99, 3-4.2.1, 3-5.2.1, 3-6.2.1

NFPA Standard: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

Based on observation and interview, the facility fails to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13, by ensuring sprinkler heads are free of foreign materials. This deficient practice could affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads, compromising the effectiveness of the fire suppression, affecting no patients and any visitors or staff in 1 of 3 smoke zones. The facility has a capacity of 12 with a census of 0 at the time of this survey.

Findings include:

During the tour conducted on 04/13/2016, at approximately 3:19 p.m., it is observed that an exterior sprinkler head located at the back door near the emergency entrance has dirt, debris and/or other foreign materials.

Facilities Director was present and acknowledged the findings.

NFPA Standard: NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3

Based on observation, record review and staff interview, the facility fails to assure that water heaters requiring a boiler inspection have been inspected and certified. Failure to comply with the State's inspection requirements could result in a hazardous condition due to improper installation or the malfunction of a heat-producing appliance, affecting approximately 0 residents and any staff or visitors in 1 of 3 smoke zones. The facility has a capacity of 12 with a census of 0 at the time of this survey.

Findings Include:

During the tour conducted on 04/13/2016, at 3:10 p.m., it is observed that posted boiler inspection certificates expired 07/22/2015.

Facilities Director was present and acknowledged the findings.

NFPA Standard: Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

Based on record review and staff interview, the facility fails to provide a remote shut-off for the generator. This deficient practice could result in the inability to remotely discontinue electrical services of the generator to avoid electrocution, affecting all patients and any staff or visitors in 3 of 3 smoke zones. The facility has a capacity of 12 with a census of 0 at the time of the survey.

Findings include:

During the tour conducted on 04/13/20106, at approximately 1:40 p.m., it is observed that there is no remote shut-off provided for the automatic diesel generator.

Facilities Director was present and acknowledged the lack of a remote shut-off for the automatic generator.

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 on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all patients and any staff or visitors in 3 of 3 smoke zones. The facility has a capacity of 12 with a census of 0 at the time of this survey.

During the tour conducted on 04/13/2016, the following is observed:

-- 1. At approximately 3:04 p.m., in Radiology, extension cords are used to power computer equipment and monitors. The cords pass between rooms through walls.

-- 2. At approximately 3:19 p.m., in Dictation Records Room, a combination of a powerstrip and extension cord used as permanent wiring for another powerstrip.

-- 3. At approximately 3:30 p.m., in the NW corner of the cubical/office area in the Business Office, a non-grounded multi-plug extension cord is in use as permanent wiring.

Facilities Director was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2000 NFPA 101, 9.1.2

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8