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Based on observation and staff interview, the facility failed to maintain doors in the stairwell enclosures in accordance with the requirements of the NFPA 101 "The Life Safety Code" 2012 edition (LSC) sections, 7.2.1.8.2, 8.3.3.3 and 19.2.2.2.7. This deficient practice could affect the safety of 2 of 13 patients as well as an undetermined number of staff, and visitors to the facility .

Findings include:

On facility tour between 10:30 a.m. to 3:30 p.m. on 08/16/2017, observations reveled that the 90 minute fire rated door to the 2nd floor stairwell labeled F did not fully close and positively latch into the door frame when tested during the survey.


This deficient condition was verified by a Maintenance Supervisor.

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection for 1 of several hazardous areas located throughout the facility in accordance with NFPA 101 "The Life Safety Code" 2012 edition (LSC) section 19.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect 8 of 13 patients as well as an undetermined number of staff, and visitors.


Findings include:

On facility tour between 10:30 a.m. to 3:30 p.m. on 08/16/2017, observations revealed that there is a 4 inch hole in the wall in the located on the inside of the network storage room that is greater than 50 square feet.


This deficient condition was verified by a Maintenance Supervisor.

Based on review of reports, records and staff interview, it was determined that the facility failed ensure staff training and participation for in accordance with the NFPA 101 "The Life Safety Code" 2012 edition (LSC) sections 19.7.1.2 and 19.7.1.6, during the last 12-month period. This deficient practice could affect 13 of 13 patients, as well as an undetermined number of staff, and visitors.


Findings include:

On facility tour between 10:30 a.m. to 3:30 p.m. on 08/16/2017, during the review of all available fire drill documentation and interview with the Maintenance Supervisor it was found that the facility could not provide documentation annotated all of the staff members that had been evolved with a fire drill and fire evacuation training for 6 of 12 fire drills.


This deficient condition was verified by a Maintenance Supervisor.

Based on observation and staff interview, the facility has failed to provide a complete and current facility Risk Assessment in accordance with the NFPA 99 "Health Care Facilities Code" 2012 edition section 4.1. This deficient practice could affect 13 of 13 patients, as well as an undetermined number of staff, and visitors.


Findings include:

On facility tour between 10:30 a.m. to 3:30 p.m. on 08/16/2017, during the documentation review and an interview with the maintenance Supervisor it was revealed that the facility could not provide any risk assessment documenting or proof that the risk assessment had been completed at the time of the inspection.


This deficient condition was verified by a Maintenance Supervisor.

Based on observations and staff interview, that the electrical testing and maintenance was not maintained in accordance with NFPA 99 Standards for Health Care Facilities 2012 edition, section 10.3. This deficient practice could create an oxygen enriched atmosphere that could contribute to rapid fire growth. This could negatively affect 13 of 13 patients as well as an undetermined number of staff, and visitors to the facility.

Findings include:

On facility tour between 10:30 a.m. to 3:30 p.m. on 08/16/2017, during a records review and an interview with the Maintenance Supervisor, the facility could not provide any documentation for the completion of the annual electrical outlet inspection and testing for the electrical outlets located in the patient rooms located throughout the facility.


This deficient condition was verified by a Maintenance Supervisor.

Based on documentation review and staff interview, the facility failed to test and maintain the emergency generator in accordance with the requirements of the NFPA 101 "The Life Safety Code" 2012 edition (LSC) sections, 9.1.3.1 and NFPA 110 "Standard for Emergency and Standby Power Systems. This deficient practice could affect the safety of 13 of 13 patients as well as an undetermined number of staff, and visitors to the facility.

Findings include:

On facility tour between 10:30 a.m. to 3:30 p.m. on 08/16/2017, during the review of all available emergency generator maintenance documentation and an interview with the Maintenance Supervisor it was revealed that the facility did not have documentation for 21 of 54 weekly inspections of the facility's emergency generator.


This deficient condition was verified by a Maintenance Supervisor.