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Based on observation and interview, it was determined the facility failed to maintain fire rated construction components affecting one of four smoke compartments this component.

Findings include:

1. Observation on June 5, 2015, 11:17 AM, revealed a gap in the one-hour fire rated suspended ceiling assembly located outside the Director of Nursing's office.

Exit interview with facility administrator and maintenance representative #1 on June 5, 2015, between 11:45 AM and 12:00 PM, confirmed the opening in the fire rated ceiling outside the DON ' s office.

Based on documentation review and interview, it was determined the facility failed to conduct three required quarterly fire drills during the last year, affecting one of one floors in this component.

Findings include:

1. Review of fire drill documentation on June 5, 2015, at 10:30 AM revealed the facility did not have documentation available to support three of twelve required fire drills during the past year.

Exit interview with facility administrator and maintenance representative #1 on June 5, 2015, between 11:45 AM and 12:00 PM, confirmed the fire drills were not conducted.

Based on documentation review and interview, it was determined the facility failed to maintain the dietary hood fire suppression system affecting one of four smoke compartments in this component.

Findings include:

1. Review of dietary hood fire suppression system inspection documentation on June 5, 2015, at 9:57 AM, revealed the system had been Red-tagged/declared as being out of compliance by the vendor on 5/29/2015.

Exit interview with facility administrator and maintenance representative #1 on June 5, 2015, between 11:45 AM and 12:00 PM, confirmed the dietary hood fire suppression system did not have the appropriate coverage for the cooking equipment it was protecting.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting one of one floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on June 5, 2015, at 9:50 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with facility administrator and maintenance representative #1 on June 5, 2015, between 11:45 AM and 12:00 PM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels.

Based on observation and interview, it was determined the facility failed to maintain fire rated construction components affecting one of four smoke compartments this component.

Findings include:

1. Observation on June 5, 2015, 11:17 AM, revealed a gap in the one-hour fire rated suspended ceiling assembly located outside the Director of Nursing's office.

Exit interview with facility administrator and maintenance representative #1 on June 5, 2015, between 11:45 AM and 12:00 PM, confirmed the opening in the fire rated ceiling outside the DON ' s office.

Based on documentation review and interview, it was determined the facility failed to conduct three required quarterly fire drills during the last year, affecting one of one floors in this component.

Findings include:

1. Review of fire drill documentation on June 5, 2015, at 10:30 AM revealed the facility did not have documentation available to support three of twelve required fire drills during the past year.

Exit interview with facility administrator and maintenance representative #1 on June 5, 2015, between 11:45 AM and 12:00 PM, confirmed the fire drills were not conducted.

Based on documentation review and interview, it was determined the facility failed to maintain the dietary hood fire suppression system affecting one of four smoke compartments in this component.

Findings include:

1. Review of dietary hood fire suppression system inspection documentation on June 5, 2015, at 9:57 AM, revealed the system had been Red-tagged/declared as being out of compliance by the vendor on 5/29/2015.

Exit interview with facility administrator and maintenance representative #1 on June 5, 2015, between 11:45 AM and 12:00 PM, confirmed the dietary hood fire suppression system did not have the appropriate coverage for the cooking equipment it was protecting.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator affecting one of one floors in this component.

Findings include:

1. Review of emergency generator inspection and testing documentation on June 5, 2015, at 9:50 AM, revealed the facility did not have documentation available to support conducting a weekly observation of the emergency generator starting battery electrolyte levels for the past year.

Exit interview with facility administrator and maintenance representative #1 on June 5, 2015, between 11:45 AM and 12:00 PM, confirmed the facility did not have a record of weekly inspection of emergency generator starting battery electrolyte levels.