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Based on observation, record review and interview, the facility failed to provide self-closing devices on doors to hazardous areas. The deficient practice would prevent self-closing of doors when released to self-closing action, affecting approximately 8 patients and all visitors and staff in 1 of 8 smoke zones. This facility has a capacity of 26 and a census of 4 at the time of the survey.

Findings include:

-- 1. Observation on 05/07/2015, at approximately 3:20 p.m., room #218 (a resident room converted to a combustible storage room in excess of 50 square feet) revealed that the corridor door was not equipped with a self-closing device.

Maintenance Director was present and confirmed the observations and findings at the time of discovery.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on interview and record review, the facility failed to assure that exit and directional signs are continuously illuminated. The deficient practice could result in a person's inability to rapidly identify the exit, affecting no patients and any visitors and staff in 1 of 8 smoke zones. The facility has a capacity of 26 and a census of 4 patients at the time of the survey.

Findings include:

During the tour conducted on 05/07/2015, at approximately 2:50 p.m., it is observed that the exit sign located at the north exit near the business office is not illuminated.

Maintenance Director verified these observations during the survey process and confirmed there were no other records.

NFPA Standard: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 7.10.2

NFPA Standard: Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted. 2000 NFPA 101, 7.10.1.7

Based on interview and record review, the facility failed to provide a written plan for the evacuation of the buildings smoke zones directly affected by fire. The deficient practice affected all smoke zones, all residents and staff. This facility has a capacity of 26 and a census of 4 residents at the time of the survey.

Findings include:

During the tour conducted on 05/07/2015, at approximately 12:25 p.m., a review of records revealed the facility did not have a smoke zone evacuation plan. The evacuation plan for the facility was for total evacuation of the building and did not have a plan for evacuation of a smoke zone directly affected by fire conditions. Interview with the facility Maintenance Director and Maintenance Staff A indicated that the facility trained staff to evacuate a smoke zone on fire, but did not have a written policy.

Maintenance Director verified these observations during the survey process and confirmed there were no other records.

NFPA Standard: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 2000 NFPA 101, 18/19.7.1.1

NFPA Standard: A written health care occupancy fire safety plan shall provide for the following: 1) Use of alarms 2) Transmission of alarm to the fire department 3) Response to alarms 4) Isolation of fire 5) Evacuation of immediate area 6) Evacuation of smoke compartment 7) Preparation of floors and building for evacuation 8) Extinguishment of fire. 2000 NFPA 101, 18/19.7.2.2

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70 and fails to prohibit the use of flexible cords and cables as permanent wiring. The deficient practice increases the risk of an electrical fire, affecting approximately no patients and any visitors and staff in 1 of 8 smoke zones. The facility has a capacity of 26 with a census of 4 at the time of the survey.

Findings include:

During the tour conducted on 05/07/2015, at approximately 2:55 p.m., in the business office break room, it is observed that a multi-plug extension cord is used to provide power to a coffee pot and toaster.

Maintenance Director was present and acknowledged the non-approved use of an extension cord.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation, record review and interview, the facility failed to provide self-closing devices on doors to hazardous areas. The deficient practice would prevent self-closing of doors when released to self-closing action, affecting approximately 8 patients and all visitors and staff in 1 of 8 smoke zones. This facility has a capacity of 26 and a census of 4 at the time of the survey.

Findings include:

-- 1. Observation on 05/07/2015, at approximately 3:20 p.m., room #218 (a resident room converted to a combustible storage room in excess of 50 square feet) revealed that the corridor door was not equipped with a self-closing device.

Maintenance Director was present and confirmed the observations and findings at the time of discovery.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on interview and record review, the facility failed to assure that exit and directional signs are continuously illuminated. The deficient practice could result in a person's inability to rapidly identify the exit, affecting no patients and any visitors and staff in 1 of 8 smoke zones. The facility has a capacity of 26 and a census of 4 patients at the time of the survey.

Findings include:

During the tour conducted on 05/07/2015, at approximately 2:50 p.m., it is observed that the exit sign located at the north exit near the business office is not illuminated.

Maintenance Director verified these observations during the survey process and confirmed there were no other records.

NFPA Standard: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 7.10.2

NFPA Standard: Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted. 2000 NFPA 101, 7.10.1.7

Based on interview and record review, the facility failed to provide a written plan for the evacuation of the buildings smoke zones directly affected by fire. The deficient practice affected all smoke zones, all residents and staff. This facility has a capacity of 26 and a census of 4 residents at the time of the survey.

Findings include:

During the tour conducted on 05/07/2015, at approximately 12:25 p.m., a review of records revealed the facility did not have a smoke zone evacuation plan. The evacuation plan for the facility was for total evacuation of the building and did not have a plan for evacuation of a smoke zone directly affected by fire conditions. Interview with the facility Maintenance Director and Maintenance Staff A indicated that the facility trained staff to evacuate a smoke zone on fire, but did not have a written policy.

Maintenance Director verified these observations during the survey process and confirmed there were no other records.

NFPA Standard: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 2000 NFPA 101, 18/19.7.1.1

NFPA Standard: A written health care occupancy fire safety plan shall provide for the following: 1) Use of alarms 2) Transmission of alarm to the fire department 3) Response to alarms 4) Isolation of fire 5) Evacuation of immediate area 6) Evacuation of smoke compartment 7) Preparation of floors and building for evacuation 8) Extinguishment of fire. 2000 NFPA 101, 18/19.7.2.2

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70 and fails to prohibit the use of flexible cords and cables as permanent wiring. The deficient practice increases the risk of an electrical fire, affecting approximately no patients and any visitors and staff in 1 of 8 smoke zones. The facility has a capacity of 26 with a census of 4 at the time of the survey.

Findings include:

During the tour conducted on 05/07/2015, at approximately 2:55 p.m., in the business office break room, it is observed that a multi-plug extension cord is used to provide power to a coffee pot and toaster.

Maintenance Director was present and acknowledged the non-approved use of an extension cord.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8