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Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of five smoke compartments. This facility has a capacity of 25 and a census of 0 patients.

Findings include:

Observation and staff interview of the boiler room on 9/20/16 at 3:32 p.m. revealed a 1/2 inch penetration surrounding a cable bundle on the North wall in the corner. Maintenance Staff confirmed this observation during the survey process.

Based on observation, record review and staff interview, the facility failed to hold 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. This facility has a capacity of 25 with a census of 0.

Findings include:

Observation and staff interview on 9/20/16 at 2:32 p.m., the facility fire drill documentation showed that all of the first shift drills were conducted within the same hour for all four quarters. Maintenance Staff verified the documentation during the survey process.

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect five out of five smoke compartments and all of the residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 0.

Findings include:

1. Documentation review and staff interview on 9/20/16 at 3:40 p.m. with Maintenance Staff could not provide documentation showing that the generator monthly inspections run for 30 minutes at 30 percent load.
Maintenance Staff verified this observation during the survey process.
2. Observation on 9/20/16 at 3:40 p.m. revealed no remote manual stop station (emergency shut off) for the generator. Maintenance Staff verified this observation during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of five smoke compartments. This facility has a capacity of 25 and a census of 0 patients.

Findings include:

Observation and staff interview of the boiler room on 9/20/16 at 3:32 p.m. revealed a 1/2 inch penetration surrounding a cable bundle on the North wall in the corner. Maintenance Staff confirmed this observation during the survey process.

Based on observation, record review and staff interview, the facility failed to hold 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. This facility has a capacity of 25 with a census of 0.

Findings include:

Observation and staff interview on 9/20/16 at 2:32 p.m., the facility fire drill documentation showed that all of the first shift drills were conducted within the same hour for all four quarters. Maintenance Staff verified the documentation during the survey process.

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect five out of five smoke compartments and all of the residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 0.

Findings include:

1. Documentation review and staff interview on 9/20/16 at 3:40 p.m. with Maintenance Staff could not provide documentation showing that the generator monthly inspections run for 30 minutes at 30 percent load.
Maintenance Staff verified this observation during the survey process.
2. Observation on 9/20/16 at 3:40 p.m. revealed no remote manual stop station (emergency shut off) for the generator. Maintenance Staff verified this observation during the survey process.