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Based on observation and interview, the facility failed to provide a placard for the use of the K-type fire extinguisher in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (Section-10.2.2), 2011 Edition. This deficient practice affects all staff in the Kitchen. This facility has a capacity of 16 and a census of 7.

Findings include:

Observation and interview on 4/23/2019 10:45 a.m., revealed the facility failed to provide a placard at the K-type fire extinguisher located in the Kitchen that states the extinguisher is to be used only after the fixed suppression system has been actuated. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and record review, the facility did not provide and maintain complete documentation or provide 100% semi-annual testing of the fire alarm system as required by NFPA 72. This deficient practice of not providing complete and verifiable documentation of the inspection, testing, and maintenance of the fire alarm system does not ensure proper operation and prompt repair affecting all occupants in the facility. The facility has a capacity of 16 with a census of 7.

Findings include:

1. Observation and record review on 4/23/2019 at 10:01 a.m., revealed the fire alarm inspection forms dated 6/29/2018 and 12/11/2018 failed to contain detailed lists of all of the devices. The fire alarm inspection and testing forms failed to document that 100% of the devices were tested annually as required by NFPA 72. The Maintenance Director verified this through record review and interview at the time of the survey process.

2. Observation and interview on 4/23/2019 at 12:43 p.m., revealed the facility failed to maintain the fire alarm system in Office #134. This room contain a strobe that was obstructed by cabinets along the south wall. The Maintenance verified this observations at the time of the survey process.

Based on observation and record review, the facility did not assure that an adequate policy is in place regarding the procedures to be taken in the event that the fire alarm is out of service for more than four hours in any 24-hour period in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. Lack of written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. This deficient practice affects all occupants of the building in the facility with a capacity of 16 and a census of 7.

Findings include:

Observation and record review on 4/23/2019, at 10:03 a.m., revealed the fire alarm outage procedures from the Emergency manual failed to include telephone numbers to the Department of Inspection & Appeals and Insurance Carrier. The Maintenance Director verified this through record review at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2010 edition of NFPA 25, by ensuring that sprinkler heads have an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 16 and a census of 7.

Findings include:

Observation and interview on 04/23/2019 at 10:55 a.m., revealed the facility failed to maintain the sprinkler system in Sleep Lab Room #417. This room contained plastic three ring binders stored directly under the sprinkler head in the closet. The Maintenance Director verified this observation at the time of the survey process.

Based on interview and record review, the facility did not assure that a complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affected all occupants of the building. This facility had a capacity of 16 and a census of 7 at the time of the survey.

Findings include:

Record review and interview on 4/23/2019 at 10:10 a.m., revealed the facility did not have a sprinkler system outage policy to address procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period. The policy did not contain an Impairment Coordinator. The Maintenance Director verified this observation through record review at the time of the survey process.

Based on observation this facility is not assuring that one of three smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects 7 staff in the facility. The facility has a capacity of 16 with a census of 7.

Findings include:

Observation and interview on 4/23/2019 at 12:45 p.m., revealed the smoke barrier near Office #405 contained three flex conduits with a 3/4 inch gap above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, affecting one staff or resident in this room. The facility had a capacity of 16 and a census of 7.

Findings Include:

1. Observation and interview on 04/23/2019 at 11:00 a.m., revealed the facility failed to maintain the electrical system in ENT Office #100. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 04/23/2019 at 11:15 a.m., revealed the facility failed to maintain the electrical system in Office #107. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

3. Observation and interview on 04/23/2019 at 11:30 a.m., revealed the facility failed to maintain the electrical system in Office #106. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

4. Observation and interview on 04/23/2019 at 11:40 a.m., revealed the facility failed to maintain the electrical system in Exam Room #115. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

5. Observation and interview on 04/23/2019 at 11:42 a.m., revealed the facility failed to maintain the electrical system in Exam Room #114. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

6. Observation and interview on 04/23/2019 at 11:50 a.m., revealed the facility failed to maintain the electrical system in Exam Room #121. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

7. Observation and interview on 04/23/2019 at 11:52 a.m., revealed the facility failed to maintain the electrical system in Exam Room #122. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

8. Observation and interview on 04/23/2019 at 11:54 a.m., revealed the facility failed to maintain the electrical system in Exam Room #125. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

9. Observation and interview on 04/23/2019 at 12:00 p.m., revealed the facility failed to maintain the electrical system in Exam Room #126. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

10. Observation and interview on 04/23/2019 at 12:42 a.m., revealed the facility failed to maintain the electrical system in Exam Room #127. This room contained a standard outlet near the sink that was not G.F.C.I. protected. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1/19.7.1 and 18.7.2/19.7.2. The fire plan did not include information on all of the types of fire extinguishers and range hood and how to operate them. This deficient practice affects all smoke zones and all occupants. This facility had a capacity of 16 and a census of 7 at the time of the survey process.

Findings include:

1. Observation and record review on 4/23/2019 at 10:40 a.m., revealed the emergency plans failed to contain the different types of fire extinguishers and how to use them. The Maintenance Director verified this through record review at the time of the survey process.

2. Observation and record review on 4/23/2019 at 10:45 a.m., revealed the emergency plans failed to contain the information about the range hood and how to use them. The Maintenance Director verified this through record review at the time of the survey process.

Based on observation and record review, the facility failed to conduct and document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects all residents, staff, and visitors in the facility. The facility had a capacity of 16 and a census of 7.

Findings include:

Observation and record review on 4/23/2019, at 10:30 a.m., revealed the facility was unable to provide documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. The Maintenance Director verified this through record review at the time of the survey process