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Based on a tour of the building and staff interviews it was revealed the facility failed to ensure that required emergency building exits were maintained free of obstructions in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all residents, staff and visitors in the areas referenced. Facility census four (4).

Findings include:

1. On 08/20/19 at approximately 1:20 p.m. a tour of the building revealed the discharge exit from the laboratory steps were blocked and handrails at ground level of the steps were loaded with lumber blocking access to the public way.

2. On 08/20/19 at approximately 1:30 p.m. these findings were verified with the Maintenance Supervisor. The findings were also acknowledged by the Administrator at the exit interview on 08/21/19 at approximately 3:30 p.m.

Based on record review and staff interviews it was revealed the facility failed to ensure that required emergency lighting systems were tested in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all residents, staff and visitors in the areas referenced. Facility census four (4).

Findings include:

1. On 08/19/19 at approximately 11:20 a.m. documentation review revealed no documentation of the battery powered emergency lights located throughout the facility and that off site facilities had received monthly functional testing for not less than thirty (30) seconds.

2. On 08/19/19 at approximately 11:20 a.m. documentation review revealed no documentation of the battery powered emergency lights located throughout the facility and that the off site facilities had received annual functional testing for a minimum of ninety (90) minutes.

3. On 08/19/19 at approximately 12:30 p.m. these findings were verified with the Maintenance Supervisor. The findings were also acknowledged by the Administrator at the exit interview on 08/13/19 at approximately 3:30 p.m.

Based on observation and staff interviews it was revealed the facility failed to ensure that portable fire extinguishers were installed and maintained in accordance with National Fire Protection Association (NFPA) 10. This deficient practice could affect all patients, staff and visitors in the areas referenced. Facility census four (4).

Findings include:

1. On 08/20/19 at approximately 1:32 p.m. it was revealed the fire extinguisher located near the lab stairwell was mounted in a way that had the top of the fire extinguisher greater than five (5) feet above the floor.

2. On 08/20/19 at approximately 1:39 p.m. it was revealed the fire extinguisher located near room 117 was mounted in a way that had the top of the fire extinguisher greater than five (5) feet above the floor.

3. On 08/20/19 at approximately 1:41 p.m. it was revealed the fire extinguisher located outside of room 146 was mounted in a way that had the top of the fire extinguisher greater than five (5) feet above the floor.

4. On 08/20/19 at approximately 1:45 p.m. it was revealed the fire extinguisher located near the Administrator's office on the second floor was mounted in a way that had the top of the fire extinguisher greater than five (5) feet above the floor.

5. On 08/20/19 at approximately 1:47 p.m. it was revealed the fire extinguisher located outside of the physical therapy area was mounted in a way that had the top of the fire extinguisher greater than five (5) feet above the floor.

6. On 08/20/19 at approximately 1:49 p.m. it was revealed the fire extinguisher located near the Maintenance Supervisor's office was mounted in a way that had the top of the fire extinguisher greater than five (5) feet above the floor.

7. On 08/20/19 at approximately 1:55 p.m. it was revealed the fire extinguisher located in central supply was mounted in a way that had the top of the fire extinguisher greater than five (5) feet above the floor.

8. On 08/20/19 at approximately 2:00 p.m. these findings were verified with the Maintenance Supervisor. The findings were also acknowledged by the Administrator at the exit interview on 08/13/19 at approximately 3:30 p.m.

Based on record review and staff interviews it was revealed the facility failed to ensure that fire drills are held at unexpected times under varying conditions, at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101. Facility census four (4).

Findings include:

1. On 08/12/19 at approximately 1:32 p.m. record review revealed the drills for day shift, first quarter and drills for day shift, second quarter were conducted within thirty (30) minutes of each other.

2. On 08/12/19 at approximately 1:32 p.m. record review revealed the drills for second shift, first quarter and drills for second shift, second quarter were conducted within eight (8) minutes of each other.

3. On 08/12/19 at approximately 1:32 p.m. record review revealed the drills for third shift, first quarter and drills for third shift, second quarter were conducted within thirty-four (34) minutes of each other.

4. On 08/12/19 at approximately 1:32 p.m. record review revealed the drills for day shift, third quarter and drills for day shift, fourth quarter were conducted within seventeen (17) minutes of each other.

5. On 08/12/19 at approximately 1:32 p.m. record review revealed the drills for second shift, third quarter and drills for second shift, fourth quarter were conducted within thirty-seven (37) minutes of each other.

6. On 08/12/19 at approximately 1:32 p.m. record review revealed the drills for third shift, third quarter and drills for third shift, fourth quarter were conducted within eight (8) minutes of each other.

7. On 08/21/19 at approximately 1:40 p.m. these findings were verified with the Maintenance Supervisor. The findings were also acknowledged by the Administrator at the exit interview on 08/21/19 at approximately 3:00 p.m.

Based on record review and staff interviews it was revealed the facility failed to provide documentation of inspecting and testing of door assembly's in accordance with National Fire Protection Association (NFPA) 80. This deficient practice could affect all residents, staff and visitors in the areas referenced. Facility census four (4).

Findings include:

1. On 08/19/19 at approximately 11:20 a.m. documentation review revealed no documentation of testing or inspecting of fire and smoke rated door assembly's.

2. On 08/19/19 at approximately 12:30 p.m. these findings were verified with the Maintenance Supervisor. The findings were also acknowledged by the Administrator at the exit interview on 08/13/19 at approximately 3:30 p.m.