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Based on observation and interview, the facility failed to provide battery powered emergency lighting in the electrical room where the controls and switches for the emergency generator are located. This deficient practice would cause confusion and delay repairs to the generator equipment in the event of a generator failure during an emergency. The facility has the capacity for 25 beds with a census of 9 on the day of survey.

Findings are:
Observation on 3-12-24 at 10:55 am revealed there was no emergency light fixture with back-up battery power provided in the room containing the controls and switches for the emergency generator.
During an interview on 3-12-24 at 10:55 am, Maintenance Staff A confirmed the findings.

NFPA 110, 2010 ed. 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall
be provided with battery-powered emergency lighting. This
requirement shall not apply to units located outdoors in enclosures
that do not include walk-in access.

Based on observation and interview, the facility failed to maintain the proper separation, and to assure the doors to hazardous areas would close and latch within the doorframe. This deficient practice would allow fire, smoke, and gases to migrate into the exit corridors. The facility has the capacity for 25 beds with a census of 9 on the day of survey.
Findings are:
Observations on 03-12-24 between 10:23 am and 12:10 pm revealed the following:

1. The door to the elevator mechanical room failed to fully close and latch within the door frame.
2. Approximately seven - 2 inch holes in the west wall of the 76 boiler room.
3. A 4 foot by 4 foot section of sheetrock missing in the ceiling of the main 76 building electrical room.
4. The north door to the laboratory room failed to latch within the door frame.

During interviews on 02-12-24 between 10:23 am and 12:10 pm, Maintenance Staff A confirmed the findings.