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Based on observation and staff interview, the facility failed to maintain all 2 hour rated walls with doors at least 1-1/2 hour fire rated in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 4/4/17 at 2:42 p.m., revealed a penetration, (approximately 1/4 inch), around an insulated pipe extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain corridor all exit corridors to be clear and unobstructed in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.2.3.5. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 4/4/17 at 2:50 p.m., revealed carts being stored in the exit corridor by the GI Room. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to test and maintain the emergency lighting system in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 7.9 and 19.2.9.1. A monthly test of the system for 30 seconds shall be conducted. A yearly test of the system for 90 minutes shall be conducted. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Record review and staff interview on 4/4/17 at 1:42 p.m., revealed the documentation of testing of the emergency lighting system listed an annual test for 30 minutes and not 90 minutes as required. Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, the facility is not properly separating hazardous areas from other compartments. Hazardous areas shall be separated from other compartments by fire rated construction and self-closing doors in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.2.1. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observations and staff interview on 4/4/17, between 1:00 p.m. and 3:30 p.m., revealed the following deficiencies:
1. There was a penetration, (approximately 1/2 inch), around a dryer vent extending through the wall of the Environmental Services Room.
2. Room 107 was being used for storage. The door to the room was not equipped with an automatic closure device.
Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observations and staff interview on 4/4/17, between 1:00 p.m. and 3:30 p.m., revealed the following deficiencies:

1. There were storage items placed within 18 inches of a sprinkler head in the X-ray Storage Room.
2. There were storage items placed within 18 inches of a sprinkler head in the Lab Storage Room.
3. There was a dirty sprinkler head in the Speech Therapy Room.

Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observations and staff interview on 4/4/17, between 1:00 p.m. and 3:30 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 1 inch), around a flexible conduit extending through the smoke barrier wall by Physical Therapy.
2. There was a penetration, (approximately 1 inch by 3 inches), around a conduit extending through the smoke barrier wall by the Radiology Manager Office.

Maintenance Staff verified observations during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills and maintain proper documentation of fire drills under varied conditions at different times of the day. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Record review and staff interview on 4/4/17 at 1:59 p.m., revealed the following deficiencies:
1. Fire drills were not conducted under varied conditions at different times of the day as follows for the 2nd shift: 2/29/16 at 7:30 p.m., 5/27/16 at 7:05 p.m., 8/8/16 at 7:12 p.m.
2. Fire drills were not conducted under varied conditions at different times of the day as follows for the 3rd shift: 3/25/16 at 5:40 a.m., 6/10/16 at 5:50 a.m., 12/16/16 at 6:00 a.m., 3/27/16 at 5:50 a.m.
3. The facility is conducting silent drills on the 3rd Shift. The facility is not testing the fire alarm within 24 hours of conducting a silent drill.
Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, the facility failed to maintain and test the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. A weekly inspection of the generator shall be conducted. monthly test under load shall be conducted. A remote manual stop station shall be provided for each generator set. The deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 4/4/17 at 2:25 p.m., revealed the annunciator panel for Generator #2 failed the lamp test. Lights on the panel failed to illuminate during the test. Maintenance Staff verified observations during the survey process.