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Based on observation and interview, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2010 Edition, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 17 and a census of 4 residents.

Findings include:

Observations on 6-6-19, revealed the following areas had air diffusers that were located within three feet of the smoke detectors:

1. Smoke detector next to air diffuser in the Acute Nurses Station.
2. Smoke detector next to air diffuser in the OB Hall next to the Acute Nurses Station.

Maintenance Staff (A) verified these observations.

Observation and interview the facility failed to maintain the sprinkler system in accordance with the 2011 edition of NFPA 25, by ensuring that the sprinkler system contains the proper components. This item could effect the accessibility of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 17 and a census of 4.

Findings include:

The facility failed to properly maintain the sprinkler system in accordance with NFPA 25 as evidenced by:

1. Observation and interview on 6-6-19 at approximately 12:43 p.m., showed the sprinkler system fire department connection located on the west outside wall of the facility did not contain a fire alarm strobe, which could prevent the sprinkler system from being visible to fire fighters for fire pump accessibility.

2. Observation and interview on 6-6-19 at approximately 12:45 p.m., showed the sprinkler system riser did not contain a sprinkler head wrench for the replacement sprinkler heads.

3. Observation and interview on 6-6-19 at approximately 12:56 p.m., showed the sprinkler head in the MFRC Supply Closed was obstructed by storage on top of storage cabinets approximately 3 inches from the sprinkler head. The storage was removed by Maintenance Staff (A) at the time of the inspection.

4. Observation and interview on 6-6-19 at approximately 1:42 p.m., showed the sprinkler head in the OB Hall Electrical Room was a ceiling mounted head. The head was supplied by a flex pipe which was not properly mounted and zip tide facing horizontal not in the vertical position.

These observations were verified with Maintenance Staff (A).

Based on observations and interview, the facility is not ensuring resident room doors, office doors, and other ancillary area doors to the corridor resist the passage of smoke in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.6.3.1. This deficient practice would not prevent the spread of smoke, affecting one of three smoke compartments and could affect all residents, staff, and visitors in the facility. This facility has a capacity of 17 with a census of 4.

Findings include:

1. Observation and interview on 6-6-19 at 1:35 p.m., revealed the door to Patient Room #106 contained two leafs with the north leaf being a dead leaf. When the door was in the closed and latched position there was a 1/2 gap between the door leafs.

2. Observation and interview on 6-6-19 at 1:47 p.m., revealed the door to the X-ray File Storage Room contained a door wedge preventing the door from closing with the self closing device.

The Maintenance Director (A) confirmed these observations during the survey process.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, 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. This facility has a capacity of 17 residents with a census of 4.

Findings include:

Record review and interview on 6-6-19 at 11:30 a.m. of the facility's fire drill documentation, revealed second, and third shift drills were conducted at approximately the same time of day. Two second shift drills were conducted between 6:00 p.m. and 6:30 p.m.: on 3-18-19 at 6:00 p.m. and on 12-26-18 at 6:30 p.m.. Three second shift drills were conducted between 2:00 a.m. and 2:25 a.m.: on 5-24-19 at 2:25 a.m. and on 8-16-18 at 2:00 a.m. The Maintenance Director verified the documentation during the survey process.

Based on record review, this facility is not conduct an annual main and circuit breaker inspection and testing. The deficient practice of not providing complete and verifiable documentation on the inspection, testing and maintenance of electrical systems did not ensure prompt repair of equipment. This facility had a capacity of 17 and a census of 4 residents at the time of the survey.

Findings include:

Record review conducted on 6-6-19, revealed the facility was unable to provide an assessment of main and circuit breakers for the emergency generator.

Maintenance Staff A at the time of exit.