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Based upon observation, documentation review, and interview it was determined that the facility failed to maintain emergency lighting in one instance throughout the facility.

Findings Include:

1. Observation on July 9, 2014, revealed the following emergency lighting deficiency:

a) At 10:48 a.m. the facility lacked required documentation verifying that the emergency lighting was being tested for thirty seconds monthly.

Interview with the Chief Financial Officer and Maintenance Director on July 9, 2014, at 1:00p.m., confirmed the emergency lighting deficiency.

Based upon observation, documentation review, and interview it was determined that the facility failed to maintain exit and direction signs in one instance throughout the facility.

Findings Include:

1. Observation on July 9, 2014, revealed the following exit and directional sign deficiency:

a) At 10:48 a.m. the facility lacked required documentation verifying that the exit and directional signs were being inspected monthly.

Interview with the Chief Financial Officer and Maintenance Director on July 9, 2014, at 1:00p.m., confirmed the exit and directional sign deficiency.

Based upon observation, documentation review, and interview it was determined that the facility failed to conduct fire drills in accordance with code requirements throughout the facility.

Findings Include:

1. Observation on July 9, 2014, revealed the following exit and directional sign deficiency:

a) At 10:12 a.m. documentation indicated that the fire drills that were conducted were missing the time they were conducted in four out of twelve drills conducted. The fire drills conducted were not held at unexpected times per shift but were conducted once per quarter per shift.

Interview with the Chief Financial Officer and Maintenance Director on July 9, 2014, at 1:00p.m., confirmed the fire drill deficiency.

Based upon observation, documentation review, and interview it was determined that the facility failed to maintain inspection requirements in one instance throughout the facility.

Findings Include:

1. Observation on July 9, 2014, revealed the following generator deficiency:

a) At 10:25 a.m. the facility lacked required documentation verifying the weekly visual inspections for the generator were being completed.

Interview with the Chief Financial Officer and Maintenance Director on July 9, 2014, at 1:00p.m., confirmed the generator maintenance deficiency.

Based upon observation, documentation review, and interview it was determined that the facility failed to maintain emergency lighting in one instance throughout the facility.

Findings Include:

1. Observation on July 9, 2014, revealed the following emergency lighting deficiency:

a) At 10:48 a.m. the facility lacked required documentation verifying that the emergency lighting was being tested for thirty seconds monthly.

Interview with the Chief Financial Officer and Maintenance Director on July 9, 2014, at 1:00p.m., confirmed the emergency lighting deficiency.

Based upon observation, documentation review, and interview it was determined that the facility failed to maintain exit and direction signs in one instance throughout the facility.

Findings Include:

1. Observation on July 9, 2014, revealed the following exit and directional sign deficiency:

a) At 10:48 a.m. the facility lacked required documentation verifying that the exit and directional signs were being inspected monthly.

Interview with the Chief Financial Officer and Maintenance Director on July 9, 2014, at 1:00p.m., confirmed the exit and directional sign deficiency.

Based upon observation, documentation review, and interview it was determined that the facility failed to conduct fire drills in accordance with code requirements throughout the facility.

Findings Include:

1. Observation on July 9, 2014, revealed the following exit and directional sign deficiency:

a) At 10:12 a.m. documentation indicated that the fire drills that were conducted were missing the time they were conducted in four out of twelve drills conducted. The fire drills conducted were not held at unexpected times per shift but were conducted once per quarter per shift.

Interview with the Chief Financial Officer and Maintenance Director on July 9, 2014, at 1:00p.m., confirmed the fire drill deficiency.

Based upon observation, documentation review, and interview it was determined that the facility failed to maintain inspection requirements in one instance throughout the facility.

Findings Include:

1. Observation on July 9, 2014, revealed the following generator deficiency:

a) At 10:25 a.m. the facility lacked required documentation verifying the weekly visual inspections for the generator were being completed.

Interview with the Chief Financial Officer and Maintenance Director on July 9, 2014, at 1:00p.m., confirmed the generator maintenance deficiency.