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Based on observation and interview, the facility failed to maintain the emergency egress lighting system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by not ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. This deficient practice affects one light fixture in the facility and no residents and two staff. The facility has a capacity of 25 and a census of 8.

Findings include:

Observation and interview on 5/31/19, at 3:00 p.m., revealed the battery backup emergency light located near Room 108 failed to illuminate when tested.

The Maintenance Supervisor verified this observation at the time of the survey process.

Based on observations and interview, the facility did not provide an exit sign that is readily visible from any direction of exit access for three exit doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.10.1 and 7.10., by ensuring exit signs were illuminated. These deficient practices affected residents, staff, and visitors in the one classroom, the basement and staff lounge. The facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observations and interview on 5/31/19, between 1:15 p.m. and 1:40 p.m., revealed the following deficiencies:

1) The directional exit sign located in the Northside Classroom was not illuminated at the time of the inspection. According to the facility layout, this designated exit is a required exit.

2) The directional exit sign located in the Basement was not illuminated at the time of the inspection. According to the facility layout, this designated exit is a required exit.

3) The directional exit sign located by the Staff Lounge was not illuminated at the time of the inspection. According to the facility layout, this designated exit is a required exit.

Maintenance Staff A verified these observations at the time of discovery.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2.1.3. This deficient practice affects one of six smoke zones and could affect all residents, staff, and visitors within the affected zone. The facility had a capacity of 25 residents and a census of 8.

Findings include:

Observation and interview on 5/31/19, at 12:05 p.m., revealed the Clinic Mechanical Room Door did not contain a self-closure device on the door. This room contained a gas furnace and electrical panels.

Maintenance Staff A confirmed this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.6.1.3 and NFPA Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 10.5.5.3 by ensuring the fire alarm dedicated branch circuit(s) be mechanically protected. This deficient practice affects all occupants of the building, including clients, staff, and visitors. This facility has a capacity of 25 with a census of 8.

Findings include:

Observation and interview on 5/31/19, at 1:30 p.m., revealed the fire alarm circuit breaker, located in the Electrical Panel Room (circuit #38) was not secured with a mechanical lock.

Maintenance Staff A verified this observation during the survey.

Based on observation, record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1.2, by ensuring sprinkler heads were maintained and replaced if corroded. This deficient practice of failing to provide prompt correction of deficiencies did not ensure proper operation and prompt repair of the system. This affected three sprinkler heads in the facility. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observation and interview on 5/31/19, between 10:40 a.m. and 11:20 a.m., revealed the following deficiencies.

1) The sprinkler head located in the House Keeping Closet near Room 345 contained a green corroded sprinkler head.

2) The two sprinkler heads located in the ceiling near Room 351 were missing the escutcheon rings.

Record review of the facility layout showed this deficient practice affected two of six smoke zones.

This deficient practice was confirmed by Maintenance Staff A at the time of discovery.

Based on record review and interview, the facility did not assure that an adequate, 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 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. 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 affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Record review and interview on 5/31/19, at 10:00 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy was incomplete in that it did not address: preplanned impairments; defining emergency impairments to include system leakage, interruption of water supply, ruptured piping, and equipment failure; designating an impairment coordinator; tagging the impaired system; assembling necessary tools and materials on site.

Maintenance Staff A verified the documentation at the time of the survey process.

Based on observation and interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 edition, 7.3.1.1.1., by failing to provide an instructional placard for the K type fire extinguisher located in the kitchen. This deficient practice affects one K-type fire extinguisher in one of six smoke compartments and all staff in the kitchen. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observation and interview on 5/31/19, between 11:40 a.m. and 12:00 p.m., revealed the following deficiencies:

1) The K-type fire extinguisher located in the Kitchen did not contain an instructional placard. A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher.

2) The ABC fire extinguisher located near the Purchasing Door was mounted too high. The fire extinguisher was mounted at six feet high when measured by Maintenance Staff A.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observation, interview and record review, this facility did not assure that one of six smoke barriers are composed of materials that ensure at least a 30 minute fire resistance rating to prevent the passage of smoke and fire to another smoke zone in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.7.3. This deficient practice affected approximately 4 occupants. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observation and interview on 5/31/19, at 11:10 a.m., revealed the north wall smoke barrier located in the Boiler Mechanical Room had a bundle of phone wires passing through the wall that was not properly sealed. There was a one inch gap around the bundle that would not resist the passage of smoke. Record review of the facility layout showed the deficient practice affected one of eight barriers.

This deficient practice was confirmed by Maintenance Staff A at the times of discovery.

Based on observation, record review and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3., by ensuring corridor doors were not held open by unapproved door hold open devices. This deficient practice affected 4 occupants in one of four smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observation and interview on 5/31/19, at 1:00 p.m., revealed the door to Office #2 was being held open with a door stops. Record review of the facility layout showed this door protected one of four smoke zones.

Maintenance Staff A confirmed the finding at the time of discovery.

Based on observation, record review and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3., by ensuring corridor doors were not held open by unapproved door hold open devices. This deficient practice affected 4 occupants in one smoke zone, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observation and interview on 5/31/19, at 3:20 p.m., revealed two of two doors to the Storage Room were being held open with large yellow door stops. Record review of the facility layout showed these doors protected one of one smoke zone.

The Maintenance Supervisor confirmed the finding at the time of discovery.

Based on observations and interview, the facility is not assuring that two smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.7.3 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 4 residents, staff, and visitors in two of six smoke zones. The facility has a capacity of 25 with a census of 8.

Findings include:

Observations and interview on 5/31/19, between 11:45 a.m. and 11:48 a.m., revealed the following deficiencies:

1) There was a one inch hole located in the ceiling tile above the dryer in the Laundry Room that would not resist the passage of smoke. According to the facility layout, this was a required barrier.

2) There was a 1/2 inch gap around seven conduit pipes and a 1/2 gap around eight gas pipes that were extending through the lay in ceiling tiles in the Med Gas Room. According to the facility layout, this was a required barrier.

Maintenance Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to ensure the building's electrical system, wiring, and equipment are in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.1.2 and NFPA 70, National Electrical Code, 2011 edition, 406.6, by not ensuring receptacle faceplates are installed and electrical panels are sealed to prevent the rick of shock. The deficient practice affects all maintenance staff in the facility, including two out of six smoke zones. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observations and interview on 5/31/19, between 10:48 a.m. and 11:00 a.m., revealed the following deficiencies:

1) The electrical receptacle outlet box located near the door of the Boiler Mechanical Room was missing the cover plate.

2) The electrical panel (Panel E2) located in the Northeast Mechanical Room was missing eight cover plates in the blank or unused spaces of the electrical panel.

Maintenance Staff A confirmed these observations at the time of discovery.

Based on observation and interview, the facility failed to have an emergency shut off switch installed for the boiler system, other than a central heating plant, designed and installed so combustible materials cannot be ignited by device, and has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.5.2.2., by ensuring the boiler system contained an emergency shut off in the event of an emergency shut down. This deficient practice affects all occupants of the building. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observation and interview on 5/31/19, at 11:25 a.m., revealed the boiler system did not have an emergency shut off switch installed in case of an emergency shut down.

Maintenance Staff A verified this observation during the survey process.

Based on record review and interview, the facility failed to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Record review and interview on 5/31/19, at 9:30 a.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator diesel fuel.

Maintenance Staff A confirmed these findings at the time of the survey.

Based on observation, record review and interview, the facility did not prohibit the use of power strips beyond temporary installation or as a substitute for adequate wiring causing overloaded circuits in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition and NFPA 70, National Electrical Code, 2011 edition. These deficient practices may create electrical injury and fire hazards affecting approximately one occupant in one of four smoke zones. This facility had a capacity of 25 and a census of 8 residents at the time of the survey.

Findings include:

Observation and interview on 5/31/19, at 12:50 p.m., revealed there was a microwave plugged into an unapproved power strip in the West Breakroom.

Record review of the facility layout showed the deficient practice affected one of four smoke zones.

This deficient practice was confirmed by Maintenance Staff A at the time of discovery.