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Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all residents, visitors and staff in 2 of 2 smoke zones. The facility has a capacity 17 of with a census of 8 at the time of the survey.

Findings include:

During the tour conducted on 09/21/2015, a review of records between 1:00 p.m. and 2:00 p.m. for the last 5 quarters revealed the following

-- 1. Drills documented through May 11, 2015 did not contain scenarios. Unable to determine type of fire simulated or whether appropriate action was taken.

-- 2. Documentation reflects that drills for the day shift for the 1st and 2nd quarters of 2015 and night shift for the 4th quarter of 2014 were not scenario based. Fire alarm testing and/or fire sprinkler testing was used in lieu of scenarios.

Maintenance Director and Maintenance Staff A were present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview, the facility fails to provide a remote shut-off for the generator. The deficient practices could result in the inability to remotely discontinue electrical services of the generator to avoid electrocution. The deficient practice could affect all residents and any staff or visitors in 2 of 2 smoke zones. The facility has a capacity of 17 and a census of 8 at the time of this survey.

Findings include:

During the tour conducted on 09/21/2015 at 1:56 p.m., it is observed that there is no remote shut-off provided for the automatic generator.

Maintenance Director and Maintenance Staff A were present and acknowledged the findings.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting all patients and any visitors or staff in 1 of 2 smoke zones. The facility has a capacity of 17 with a census of 8 at the time of this survey.

Findings Include:

During the tour conducted on 09/21/2015, at 2:34 p.m., in the room identified as X-Ray Darkroom, two outlets were missing coverplates.

Maintenance Director was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents and occupants in the event of a fire, affecting all residents, visitors and staff in 2 of 2 smoke zones. The facility has a capacity 17 of with a census of 8 at the time of the survey.

Findings include:

During the tour conducted on 09/21/2015, a review of records between 1:00 p.m. and 2:00 p.m. for the last 5 quarters revealed the following

-- 1. Drills documented through May 11, 2015 did not contain scenarios. Unable to determine type of fire simulated or whether appropriate action was taken.

-- 2. Documentation reflects that drills for the day shift for the 1st and 2nd quarters of 2015 and night shift for the 4th quarter of 2014 were not scenario based. Fire alarm testing and/or fire sprinkler testing was used in lieu of scenarios.

Maintenance Director and Maintenance Staff A were present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview, the facility fails to provide a remote shut-off for the generator. The deficient practices could result in the inability to remotely discontinue electrical services of the generator to avoid electrocution. The deficient practice could affect all residents and any staff or visitors in 2 of 2 smoke zones. The facility has a capacity of 17 and a census of 8 at the time of this survey.

Findings include:

During the tour conducted on 09/21/2015 at 1:56 p.m., it is observed that there is no remote shut-off provided for the automatic generator.

Maintenance Director and Maintenance Staff A were present and acknowledged the findings.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting all patients and any visitors or staff in 1 of 2 smoke zones. The facility has a capacity of 17 with a census of 8 at the time of this survey.

Findings Include:

During the tour conducted on 09/21/2015, at 2:34 p.m., in the room identified as X-Ray Darkroom, two outlets were missing coverplates.

Maintenance Director was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2