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Based upon record review and interview, the facility failed to ensure that automatic emergency lighting of 1-1/2 hour duration is provided in accordance with 7.9 as required by 19.2.9.1. This deficient practice could affect 93 occupants, all of the staff and any visitors present at the time of an emergency if the automatic emergency lighting failed to operate as designed. Findings include:

1. On 9/13/19 at 11:50 AM during review of the facility's records it was observed that there was no documentation present for the annual 90 minute testing of the automatic emergency lighting.

In an interview conducted on 9/13/19 at 11:51 AM, MS#1 verified that there was no documentation present for the annual 90 minute testing of the automatic emergency lighting.

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Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect 24 occupants, 8 staff and any visitors present in Cottage 15 at the time of a fire event if the hazardous areas were not properly enclosed. Findings include:

1. On 9/13/19 at 10:04 AM a penetration in the ceiling of the laundry room between Wings 1 and 2 was observed.

In an interview conducted on 9/13/19 at 10:05 AM, MS#1 verified there was a penetration in the ceiling of the laundry room between Wings 1 and 2.

2. On 9/13/19 at 10:15 AM a penetration in the Janitor's Closet was located in the corridor between Wings 1 and 2 was observed.

In an interview conducted on 9/13/19 at 10:16 AM, MS#1 verified there was a penetration in the Janitor's Closet located in the corridor between Wings 1 and 2.

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Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect 93 occupants, all of the staff and any visitors present at the time of a fire event if the automatic sprinkler system failed to operate as designed. Findings include:

1. On 9/13/19 at 10:00 AM it was observed that the age of the sprinklers was beyond 50 years. These sprinklers shall be replaced or representative samples from one or more sample areas shall be tested.

In an interview conducted on 9/13/19 at 10:01 AM, MS#1 verified there were sprinklers that were over 50 years in age.