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Based on observation and staff interview, the facility is not maintaining the fire resistant rating of all two hour fire rated walls as required. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Observation and staff interview on 2/9/16 at 2:28 p.m, revealed the following deficiencies:

1. There was a penetration, (approximately 1/4 inch), around communications lines extending through the 2nd Floor Two Hour Firewall separating the 1950 Building from the 1967 Building.
2. There was a hole, (approximately 2 inches), extending through the 2nd Floor Two Hour Firewall separating the 1950 Building from the 1967 Building.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility is not maintaining the fire resistant rating of all two hour fire rated walls as required. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Observation and staff interview on 2/9/16, between 10:15 a.m. and 4:15 p.m.,revealed the following deficiencies:

1. There was a penetration, (approximately 1/4 inch), around communications lines extending through the 2nd Floor Two Hour Firewall separating the 1950 Building from the 1967 Building.
2. There was a hole, (approximately 2 inches), extending through the 2nd Floor Two Hour Firewall separating the 1950 Building from the 1967 Building.
3. There were 4 holes, (approximately 4 inches), extending through the 2 Hour Firewall separating the 1967 Building from the MOB Corridor.
4. There was a penetration, (approximately 1/4 inch), around communications lines extending through the 2 Hour Firewall in the 1967 Building Corridor near the Cafeteria.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. This deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Record review and staff interview on 2/9/16 at 11:26 a.m., revealed the following deficiencies:

1. Available documentation of testing of the emergency lighting system revealed the log does not include the locations of each emergency light unit.
2. There was no available documentation of the last annual 90 minute testing of the emergency lighting system. The form used to document testing includes only the standard for the monthly 30 second test.

Maintenance Staff A verified record review during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills as required for four of four quarters reviewed. The facility is not testing the fire alarm system with 24 hours of conducting a silent drill. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Record review and staff interview on 2/9/16 at 1:27 p.m., revealed the facility is not testing the fire alarm as required within 24 hours of conducting a silent fire drill on the 3rd Shift. Maintenance Staff indicated they were not aware of the requirement.

Based on record review and staff interview, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required in accordance with NFPA 96 and NFPA 17A. Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Record review and staff interview on 2/9/16, at 12:09 p.m., revealed the Kitchen Hood and Duct Extinguishment System was not inspected every 6 months as required. Available documentation revealed one inspection of the system for 2015, dated 4/20/15. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and patients. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Record review and staff interview on 2/9/16 at 11:13 a.m., revealed the following deficiencies:

1. There was no available documentation of weekly inspections of the generator set.
2. There was no available documentation indicating that the generator set is being operated under load for 30 minutes each month at 30% of the nameplate rating as required. There is no available documentation of a 2 hour load bank test during 2015 as an alternate method to meet the test requirment under load. Maintenance Staff A verified record review during the survey process.


Based on observation and staff interview, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. The deficient practice would affect all smoke compartments and all facility staff and patients. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Observation and staff interview on 2/9/16 at 2:55 p.m., revealed the generator annunciator panel located at the East Wing Nurses Station does not monitor all required information. The annunciator panel only monitors the following: engine running, generator set supplying load and alarm silence. This is the annunciator panel which is in a location that is staffed 24 hours. The facility has an annunciator panel that monitors all required information located in the Maintenance Office. However this location is not staffed 24 hours. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to ensure that the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Record review and staff interview on 2/9/16 at 11:38 a.m., revealed the outage policy for the spinkler system does not contain phone numbers for notification of the State Fire Marshal and Department of Inspections and Appeals as joint authorities having jurisdiction. The policy also lists that a fire watch is to be conducted at intervals not to exceed 60 minutes, not 30 minutes or continuous as required. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to ensure that the policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Record review and staff interview on 2/9/16 at 11:38 a.m., revealed outage policy for the fire alarm system does not contain phone numbers for notification of the State Fire Marshal and Department of Inspections and Appeals as joint authorities having jurisdiction. The policy also lists that a fire watch is to be conducted at intervals not to exceed 60 minutes, not 30 minutes or continuous as required. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to ensure that the policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. The facility has a capacity of 25 with a census of 5 patients.

Findings include:

Record review and staff interview on 2/9/16 at 11:38 a.m., revealed the outage policy for the fire alarm system does not contain phone numbers for notification of the State Fire Marshal and Department of Inspections and Appeals as joint authorities having jurisdiction. The policy also lists that a fire watch is to be conducted at intervals not to exceed 60 minutes, not 30 minutes or continuous as required. Maintenance Staff A verified record review during the survey process.