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Based on observation and interview, this facility is not maintaining a 2-hour fire barrier in accordance with National Fire Protection Association (NFPA) Standard 101 (Section 19.1.1.4.1), Life Safety Code, 2000 Edition. This deficient practice affects approximately 6 residents, staff, and visitors in 1 of 9 smoke zones. This facility has a capacity of 25 and a census of 10.

Findings include:

1. Observation and interview on 03/01/16 at 11:54 a.m., revealed approximate 4 inch and 5 inch holes in the the 2-hour fire barrier above the lay-in ceiling tile between the ED Waiting Area and the Clinic.

2. Observation and interview on 03/01/16 at 11:54 a.m., revealed a 1/2 inch open to the center conduit that penetrates the 2-hour fire barrier above the lay-in ceiling tile between the ED Waiting Area and the Clinic.

3. Observation and interview on 03/01/16 at 11:54 a.m., revealed a 1/2 inch open to the center conduit containing fire alarm wires that penetrates the 2-hour fire barrier above the lay-in ceiling tile between the ED Waiting Area and the Clinic. The Facilities Director and Maintenance Staff verified these observations at the time of the survey process.

Based on observation, interview, and record review, the facility failed to maintain the battery back-up emergency egress lights. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

1. Record review and interview on 03/01/16 at 10:36 a.m., revealed no documentation for the monthly 30 second testing of the battery back-up emergency egress lights for December 2015 and February 2016.

2. Observation and interview on 03/01/16 at 11:20 a.m., revealed the battery
back-up emergency light in the Main Electrical Room failed to illuminate when tested. The Facilities Director and Maintenance Staff verified these observations at the time of the survey process.

Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice affects all occupants, as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 10.

Findings include:

Record review and interview on 03/01/16 at 10:15 a.m., revealed no documentation for a third shift fire drill for the Third Quarter of 2015. The Facilities Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 Edition. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

Record review and interview on 03/01/16 at 10:47 a.m., revealed no documentation for 6 month semi-annual testing of the fire alarm system. The last testing was dated 06/08/15. The Facilities Director and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) Standard 72 (A.5.7.4.1), National Fire Alarm Code, 1999 Edition, which requires that smoke detectors not be located in a direct airflow or closer than three feet from an air supply diffuser or return air opening. This deficient practice affects all occupants in the facility, as smoke detectors located within three feet of a direct air flow, air supply diffuser, or air return opening can impede the operation of the detector. This facility has a capacity of 25 and a census of 10.

Findings include:

1. Observation and interview on 03/01/16 at 11:50 a.m., revealed the Vending Machine Room contained a smoke detector located within 3 feet of an air return opening.

2. Observation and interview on 03/01/16 at 12:01 p.m., revealed the corridor outside the ED Nurses Station contained a smoke detector located within 3 feet of an air diffuser. The Facilities Director and Maintenance Staff verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to maintain and test portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 Edition. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

Record review and interview on 03/01/16 at 11:27 a.m., revealed all portable fire extinguishers in the facility were past the annual service date. The last annual service was dated February 2015. The Facilities Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain the buildings emergency generators in accordance with National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 1999 Edition. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

Record review and interview on 03/01/16 at 10:52 a.m., revealed no documentation for weekly visual inspections of the emergency generators for August and September of 2015. The Facilities Director and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 Edition. This deficient practice affects approximately 4 staff in 2 of 9 smoke zones. This facility has a capacity of 25 and a census of 10.

Findings include:

1. Observation and interview on 03/01/16 at 11:46 a.m., revealed the Lab Break Room contained a clock box with exposed electrical wiring.

2. Observation and interview on 03/01/16 at 12:04 p.m., revealed two 3/4 inch conduits with numerous exposed cut off wires located above the lay-in ceiling tile near OB Room #108. The Facilities Director and Maintenance Staff verified these observations at the time of the survey process.

Based on observation and interview, this facility is not maintaining a 2-hour fire barrier in accordance with National Fire Protection Association (NFPA) Standard 101 (Section 19.1.1.4.1), Life Safety Code, 2000 Edition. This deficient practice affects approximately 6 residents, staff, and visitors in 1 of 9 smoke zones. This facility has a capacity of 25 and a census of 10.

Findings include:

1. Observation and interview on 03/01/16 at 11:54 a.m., revealed approximate 4 inch and 5 inch holes in the the 2-hour fire barrier above the lay-in ceiling tile between the ED Waiting Area and the Clinic.

2. Observation and interview on 03/01/16 at 11:54 a.m., revealed a 1/2 inch open to the center conduit that penetrates the 2-hour fire barrier above the lay-in ceiling tile between the ED Waiting Area and the Clinic.

3. Observation and interview on 03/01/16 at 11:54 a.m., revealed a 1/2 inch open to the center conduit containing fire alarm wires that penetrates the 2-hour fire barrier above the lay-in ceiling tile between the ED Waiting Area and the Clinic. The Facilities Director and Maintenance Staff verified these observations at the time of the survey process.

Based on observation, interview, and record review, the facility failed to maintain the battery back-up emergency egress lights. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

1. Record review and interview on 03/01/16 at 10:36 a.m., revealed no documentation for the monthly 30 second testing of the battery back-up emergency egress lights for December 2015 and February 2016.

2. Observation and interview on 03/01/16 at 11:20 a.m., revealed the battery
back-up emergency light in the Main Electrical Room failed to illuminate when tested. The Facilities Director and Maintenance Staff verified these observations at the time of the survey process.

Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice affects all occupants, as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 10.

Findings include:

Record review and interview on 03/01/16 at 10:15 a.m., revealed no documentation for a third shift fire drill for the Third Quarter of 2015. The Facilities Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 Edition. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

Record review and interview on 03/01/16 at 10:47 a.m., revealed no documentation for 6 month semi-annual testing of the fire alarm system. The last testing was dated 06/08/15. The Facilities Director and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) Standard 72 (A.5.7.4.1), National Fire Alarm Code, 1999 Edition, which requires that smoke detectors not be located in a direct airflow or closer than three feet from an air supply diffuser or return air opening. This deficient practice affects all occupants in the facility, as smoke detectors located within three feet of a direct air flow, air supply diffuser, or air return opening can impede the operation of the detector. This facility has a capacity of 25 and a census of 10.

Findings include:

1. Observation and interview on 03/01/16 at 11:50 a.m., revealed the Vending Machine Room contained a smoke detector located within 3 feet of an air return opening.

2. Observation and interview on 03/01/16 at 12:01 p.m., revealed the corridor outside the ED Nurses Station contained a smoke detector located within 3 feet of an air diffuser. The Facilities Director and Maintenance Staff verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to maintain and test portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 Edition. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

Record review and interview on 03/01/16 at 11:27 a.m., revealed all portable fire extinguishers in the facility were past the annual service date. The last annual service was dated February 2015. The Facilities Director and Maintenance Staff verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain the buildings emergency generators in accordance with National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 1999 Edition. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

Record review and interview on 03/01/16 at 10:52 a.m., revealed no documentation for weekly visual inspections of the emergency generators for August and September of 2015. The Facilities Director and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 Edition. This deficient practice affects approximately 4 staff in 2 of 9 smoke zones. This facility has a capacity of 25 and a census of 10.

Findings include:

1. Observation and interview on 03/01/16 at 11:46 a.m., revealed the Lab Break Room contained a clock box with exposed electrical wiring.

2. Observation and interview on 03/01/16 at 12:04 p.m., revealed two 3/4 inch conduits with numerous exposed cut off wires located above the lay-in ceiling tile near OB Room #108. The Facilities Director and Maintenance Staff verified these observations at the time of the survey process.