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Based on observation, record review and staff interview, the facility failed to test and maintain the emergency lighting system in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 7.9 and 19.2.9.1. A monthly test of the system for 30 seconds shall be conducted. A yearly test of the system for 90 minutes shall be conducted. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Observation, record review and staff interview on 2/8/17 at 12:05 p.m., revealed the following deficiencies:
1. The testing log for the emergency lighting system did not list each light with their specific location.
2. The emergency light by the CT Rooms failed to illuminate when tested.
Maintenance Staff verified record review and observation during the survey process.

Based on observations and staff interview, the facility is not properly separating hazardous areas from other compartments. Hazardous areas shall be separated from other compartments by fire rated construction and self-closing doors in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.2.1. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Observations and staff interview on 2/8/17, between 9:45 a.m. and 12:45 p.m., revealed the following deficiencies:
1. There was a gap, (approximately 1/4 inch), in the door to the Maintenance Office/Generator Room, between the door and door frame at the latch side.
2. There was a gap, (approximately 1/4 inch), in the door to the Soiled Laundry Room, between the door and door frame at the latch side. The door also failed to latch properly.
3. The double doors to the Laundry Room failed to close and latch properly.
Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to inspect and service the Kitchen Hood and Duct Extinguishment System in accordance with National Fire Protection Association, NFPA 96, 2011 edition. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Record review and staff interview on 2/8/17 at 10:43 a.m., revealed the Kitchen Hood and Duct System was inspected on 4/12/16 and 9/26/16. On both inspection reports it was noted that the system is due for 12 year hydrostatic testing. The system was noted as being installed in 2004. There was no available documentation indicating the testing had been completed.

Based on record review and staff interview, the facility failed to inspect and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. A fire alarm system shall be inspected twice a year, at an interval of 6 months. Smoke detectors shall be tested for sensitivity every 2 years. The location of the power supply for the fire alarm system shall be labeled at the main fire alarm control panel. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Record review and staff interview on 2/8/17 at 10:19 a.m., revealed the following deficiencies:

1. Available documentation indicated fire alarm inspections conducted on 11/2/16 and 3/10/16. The interval between the two inspections was in excess of 6 months.
2. The fire alarm system is an addressable system, however there was no printout of smoke detector sensitivity testing as required.
3. The location of the power supply for the fire alarm system was not labeled at the main fire alarm control panel.

Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Record review and staff interview on 2/8/17 at 10:19 a.m., revealed no available documentation of an outage policy for the fire alarm system. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Record review and staff interview on 2/8/17 at 10:19 a.m., revealed no available documentation of an outage policy for the sprinkler system. Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, the facility failed to maintain corridor walls as required. Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, and shall have a fire resistance rating of not less than 1/2 hour in accordance with 2012 Life Safety Code, 19.3.6.2, 19.3.6.2.7. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Observation and staff interview on 2/8/17, between 9:45 a.m. and 12:45 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 1/4 inch), around a sprinkler pipe hanger extending through the corridor ceiling by the entry to the Laboratory.
2. There was a penetration, (approximately 1/4 inch), around a sprinkler pipe hanger extending through the corridor ceiling by the entry to the Pharmacy.\

Maintenance Staff verified observations during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills and maintain proper documentation of fire drills under varied conditions at different times of the day 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. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Record review and staff interview on 2/8/17 at 10:43 a.m., revealed the following deficiencies:
1. Available documentation indicated fire drills were not conducted at under varied conditions at different times of the day on the 1st shift as follows: 5/15/16 at 1420. 8/31/16 at 1407. 10/29/16 at 1400.
2. Available documentation indicated fire drills were not conducted at under varied conditions at different times of the day on the 2nd shift as follows: 2/19/16 at 0524. 9/28/16 at 0500. 12/2/16 at 0500.
Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. A weekly inspection of the generator shall be conducted. A monthly test under load shall be conducted. There was no remote manual stop station for the generator. The deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Record review and staff interview on 2/8/17 at 10:06 a.m., revealed the following deficiencies:

1. The weekly generator inspection log does not contain all required information on the form. The facility is only checking "OK" on a form for inspections.
2. The monthly generator log does not contain information to ensure the generator set is being tested under load at least 30% of the nameplate rating as required for a diesel powered unit. There was no documentation of other means to meet requirements for tests under load as specified in NFPA 110.
3. There was no remote manual stop station for the generator as required.

Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, the facility failed to maintain the building's electrical system in accordance with National Fire Protection Association, NFPA 70, 2010 Edition. The facility has a capacity of 25 with a census of 4 patients.

Findings include:

Observation and staff interview on 2/8/17, between 9:45 a.m. and 12:45 p.m., revealed the following deficiencies:

1. There were two surge protectors supplying power to a microwave and a toaster in the Maintenance Office.
2. There was a plastic surge protector supplying power to a hair drying unit in the Beauty Shop.

Maintenance Staff verified observations during the survey process.