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(A)
Based on record review and interview, the facility failed to hold fire drills under varied times of the day for two 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 18 with a census of 4.

Findings include:

Record review on 10/19/2015 at 9:20 a.m. of the facility's fire drill documentation, revealed the first shift had drills for two (2) of four (4) quarters conducted between 8:35 a.m. and 9:04 a.m. and the third shift had drills for three (3) of four (4) quarters conducted between 10:30 p.m. and 11:30 p.m. The first shift drills were conducted on 07/30/15 at 8:35 a.m. and 10/06/15 at 9:04 a.m. The third shift drills were conducted on 12/29/14 at 11:30 p.m., 03/17/15 at 10:30 p.m., and 09/28/2015 at 11:00 p.m. Interview of Maintenance Staff revealed the reason most of the third shift drills were conducted at approximately the same time was because maintenance staff only worked until 12:00 a.m. Maintenance Staff and the Plant Operations Manager verified this documentation during the survey process.

(B)
Based on record review and interview, the facility failed to confirm the transmission of a fire alarm signal as required by National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition, Section 19.7.1.2. The deficient practice of failing to verify the main Fire Alarm Control Panel (FACP) communication signal was received by the monitoring company would affect all of the building occupants. This facility has a capacity of 18 and a census of 4.

Findings include:

1. Record review and interview on 10/19/2015 at 9:26 a.m. of the facility's fire drill documentation, revealed there was no record the fire alarm system was activated to test the horn and strobes during the 24 hours following the fire drill conducted on 12/29/2014 at 11:30 p.m. Maintenance Staff and the Plant Operations Manager verified this documentation during the survey process.

2. Record review on 10/19/2015 at 9:33 a.m. of the facility's fire drill documentation, revealed there was no record the monitoring company was contacted after the activation of the fire alarm system during the fire drill on any shift. Interview of Maintenance Staff revealed they were not aware of this requirement. Maintenance Staff and the Plant Operations Manager confirmed the documentation at the time of the survey.

Based on record review, the facility failed to maintain, inspect, and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition. This deficient practice affects all smoke compartments and occupants of in the facility. The facility has a capacity of 18 and a census of 4.

Findings include:

Record review of the facility's fire safety components on 10/19/2015 at 11:30 a.m., revealed the facility failed to maintain the automatic fire sprinkler system. The facility could not provide documentation of quarterly inspections for first and second quarters of 2015. Interview of Maintenance Staff revealed the inspections were likely overlooked due to multiple individuals responsible for conducting the inspections. Maintenance Staff and the Plant Operations Manager verified the documentation at the time of the survey.

(A)
Based on observation and interview, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standard 99, 1999 Edition, 3-4.1.1.15. The absence of a remote annunciator for the emergency generator would affect all smoke compartments and all of the facility occupants. The facility has a capacity of 18 and at the time of the survey the census was 4.

Findings include:

Observation and interview on 10/19/2015 at 10:25 a.m., revealed the absence of a remote annunciator panel (storage battery powered) for the emergency generator. Interview of the Plant Operations Manager revealed when work was performed on the generator years prior, the electrician doing the work said they did not need a generator annunciator panel and removed it. The Plant Operations Manager stated it was sitting in his office. Maintenance Staff and the Plant Operations Manager confirmed this observation at the time of the survey.

NFPA 99, 1999 Edition, 3-4.1.1.15, Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside the generating room in a location readily observed by operating personnel at a regular work station.

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure.
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature.
4. Low fuel-when the main fuel storage tank contains less than 3-hour operating supply.
5. Overcrank (failed to start)
6. Overspeed.

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location.

(B)
Based on observation and interview, the facility failed to ensure the emergency generator for the building was properly equipped with a remote manual stop mechanism in accordance with National Fire Protection Association (NFPA) Standard 110, 1999 Edition, 3-5.5.6. This deficient practice could affect all occupants of the facility. This facility has a capacity of 18 and a census of 4.

Findings include:

Observation on 10/19/2015 at 11:20 a.m., revealed the facility's outdoor emergency generator was not equipped with a working remote manual stop mechanism (emergency shut-off). Interview of the Maintenance Staff revealed the existing emergency shut-off was disconnected due to concerns children in the area may depress the button. Maintenance Staff verified this observation at the time of the survey process.

NFPA 110, 1999 Edition 3-5.5.6

3-5.5.6* 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.

A3-5.5.6 For level 1 and level 2 systems located outdoors the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 Edition. This deficient practice affects one of seven smoke zones. This facility has a capacity of 18 and a census of 4.

Findings Include:

1. Observation and interview on 10/19/2015 at 9:50 a.m., revealed the facility failed to maintain the electrical system in the Boiler Room. This room contained an electrical outlet along the east wall without a plate cover. Maintenance Staff confirmed this observation during the survey.

2. Observation and interview on 10/19/2015 at 10:13 a.m., revealed the facility failed to maintain the electrical system in the Public Relations Development Room. This room contained a white extension cord supplying power to a fan and a phone charger. Maintenance Staff verified this observation at the time of the survey process.

3. Observation on 10/19/2015 at 10:14 a.m., revealed the facility failed to maintain the electrical system in the Training Room. This room contained a surge protector plugged into a surge protector and a surge protector plugged in to an extension cord which was plugged into another surge protector, all supplying power to computer equipment. Interview of the Plant Operations Manager revealed the room had been set up as a temporary training area. Maintenance Staff and the Plant Operations Manager verified these observations at the time of the survey.

4. Observation and interview on 10/19/2015 at 10:17 a.m., revealed the facility failed to maintain the electrical system in the Chapel Equipment Room. This room contained an open junction box along the ceiling. Maintenance Staff verified this observation during the survey process.