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Based on observation and interview, the facility failed to provide battery powered emergency lighting in the electrical room where the controls and switches for the emergency generator are located. This deficient practice would cause confusion and delay repairs to the generator equipment in the event of a generator failure during an emergency. The facility has a capacity of 16, with a census of 8 on the date of survey.

Findings are:
Observation on 4-11-24 at 11:25 am revealed there was no battery powered emergency lighting provided in the two rooms containing the controls and switches for the emergency generators
.
During an interview on 4-11-24 at 10:25 am, Maintenance Staff A and B confirmed the findings.

NFPA 110, 2010 ed. 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall
be provided with battery-powered emergency lighting. This
requirement shall not apply to units located outdoors in enclosures
that do not include walk-in access.

Based on observation and staff interview, the facility failed to provide smoke resistant partitions to separate hazardous areas from the rest of the building. This condition would allow smoke and fire gases to migrate into the exit corridors, which would affect all occupants. The facility has a capacity of 16, with a census of 8 on the date of survey.

Findings are:
Observation on 4-11-24 at 10:02 am revealed four unsealed penetrations around conduit in the walls of the electrical room on the nursing floor.

During an interview on 4-11-24 at 10:02 am, Maintenance A and B acknowledged the findings.

Based on observation and staff interview, the facility failed to maintain doors to ensure smoke separation of the egress corridors. This condition would allow smoke and fire gases to migrate into the egress corridor. The facility capacity was 16, with a census of 8 on the date of survey.

Findings are:
Observation on 4-11-24 at 10:26 am revealed that the east corridor door to the infusion room failed to fully close and latch.

During an interview on 4-11-24 at 10:26 am, Maintenance Staff A and B confirmed the findings.