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Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the corridor doors in accordance with NFPA 101. This deficient practice could affect 1 patient and all staff and visitors in 2 of 6 smoke zones. The facility has a capacity of 25 with a census of 5 residents at the time of survey.
Findings include:

During the survey conducted on 9/27/16 the following deficiencies are noted:

1. During the survey at approximately 10:30 AM it is observed that the corridor door to outpatient room 120 appeared to be catching on the door frame and did not properly close and latch when tested.
2. During the survey at approximately 10:15 AM it is observed that the corridor door to Dexa X-Ray room was held open by a kick down device.

Maintenance staff was present and acknowledged that the corridor door that did not completely close and latch and the kick down device.

NFPA Standard: Doors in corridor walls of sprinkled buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinkled buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation, staff interview and record review, the facility is not storing compressed gas cylinders in accordance with NFPA 99, by ensuring that cylinders were adequately secured to prevent them from accidental damage or dislocation. This deficient practice could only affect staff as the deficiency is in the outside storage cage. This facility has a capacity of 25 and a census of 5 residents at the time of survey.

Findings include:
During the tour conducted on 9/27/16 the following deficiency is noted:

1. It is observed at approximately 12:00 PM that there are 2 compressed gas cylinders in the storage area outside that are not properly secured.

Staff A was present and acknowledged the unsecured compressed gas cylinders.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all patients, visitors, and staff in 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 5 residents at the time of the survey.
Findings include:

During the survey conducted on 9/27/16 the following deficiency is noted:

1. During document review at approximately 9:00 AM it is observed that there is no generator malfunction policy in place.
2. During the survey at approximately 11:30 AM it is observed that there is no emergency remote shutoff for the generator.

Maintenance staff was present and acknowledged the missing policy and the needed remote shutoff for the 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.

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting no patients and all visitors and staff in 2 of 6 smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.
Findings Include:

During the tour conducted on 9/27/16 the following deficiencies are noted:

1. During the survey at approximately 9:00 AM it is observed in the maintenance office that there is multiplug adapter in use by the desk.
2. During the survey at approximately 10:00 AM it is observed that there is an open junction box above the ceiling tiles near the outpatient clinic hall linen closet.

Maintenance Staff was present and acknowledged the open junction box and the multiplug adapter.
NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2
NFPA Standard: Multiplug adapters shall not be used as a substitute for permanent wiring or receptacles. 2000 NFPA 70, 11.1.5.2
NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).

Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the corridor doors in accordance with NFPA 101. This deficient practice could affect 1 patient and all staff and visitors in 2 of 6 smoke zones. The facility has a capacity of 25 with a census of 5 residents at the time of survey.
Findings include:

During the survey conducted on 9/27/16 the following deficiencies are noted:

1. During the survey at approximately 10:30 AM it is observed that the corridor door to outpatient room 120 appeared to be catching on the door frame and did not properly close and latch when tested.
2. During the survey at approximately 10:15 AM it is observed that the corridor door to Dexa X-Ray room was held open by a kick down device.

Maintenance staff was present and acknowledged that the corridor door that did not completely close and latch and the kick down device.

NFPA Standard: Doors in corridor walls of sprinkled buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinkled buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation, staff interview and record review, the facility is not storing compressed gas cylinders in accordance with NFPA 99, by ensuring that cylinders were adequately secured to prevent them from accidental damage or dislocation. This deficient practice could only affect staff as the deficiency is in the outside storage cage. This facility has a capacity of 25 and a census of 5 residents at the time of survey.

Findings include:
During the tour conducted on 9/27/16 the following deficiency is noted:

1. It is observed at approximately 12:00 PM that there are 2 compressed gas cylinders in the storage area outside that are not properly secured.

Staff A was present and acknowledged the unsecured compressed gas cylinders.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all patients, visitors, and staff in 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 5 residents at the time of the survey.
Findings include:

During the survey conducted on 9/27/16 the following deficiency is noted:

1. During document review at approximately 9:00 AM it is observed that there is no generator malfunction policy in place.
2. During the survey at approximately 11:30 AM it is observed that there is no emergency remote shutoff for the generator.

Maintenance staff was present and acknowledged the missing policy and the needed remote shutoff for the 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.

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting no patients and all visitors and staff in 2 of 6 smoke zones. The facility has a capacity of 25 with a census of 5 at the time of this survey.
Findings Include:

During the tour conducted on 9/27/16 the following deficiencies are noted:

1. During the survey at approximately 9:00 AM it is observed in the maintenance office that there is multiplug adapter in use by the desk.
2. During the survey at approximately 10:00 AM it is observed that there is an open junction box above the ceiling tiles near the outpatient clinic hall linen closet.

Maintenance Staff was present and acknowledged the open junction box and the multiplug adapter.
NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2
NFPA Standard: Multiplug adapters shall not be used as a substitute for permanent wiring or receptacles. 2000 NFPA 70, 11.1.5.2
NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).