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Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the five smoke compartments in the building. This deficient practice could affect 5 residents, staff and visitors. The facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 08/16/2016 at 11:15 a.m., revealed the facility failed to maintain the lower level smoke barrier doors near Conference Room #2. These double doors failed to close and positively latch while being tested. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain a directional exit sign at the end of the corridor for one of ten exits. This deficient practice affects 5 residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 08/16/2016 at 11:35 a.m., revealed the facility failed to maintain a directional exit sign in the Emergency Room corridor near exam room
#3. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Maintenance Director verified this observation at the time of the survey process.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 5.

Findings include:

Review of the facility's fire drill records on 08/16/2016 at 11:32 a.m., revealed the facility failed to conduct at least one fire drill per shift per quarter of 2015. The facility failed to provide documentation of any fire drills being conducted on the second or third shift , third quarter of 2015. The facility failed to provide documentation for any drills on the third shift fourth quarter 2015. The Maintenance Director verified this through record review 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 NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 5 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 5.

Findings include:

1. Observation and interview on 08/16/2016 at 10:45 a.m., revealed the facility failed to maintain the Fire Alarm System in the the Central Supply Storage Room. This room contained a smoke detector with in three feet of an air diffuser.

2. Observation and interview on 08/16/2016 at 11:36 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #1. This room contained a smoke detector with in three feet of an air diffuser.

3. Observation and interview on 08/16/2016 at 11:37 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #2. This room contained a smoke detector with in three feet of an air diffuser.

4. Observation and interview on 08/16/2016 at 11:38 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #3. This room contained a smoke detector with in three feet of an air diffuser.

5. Observation and interview on 08/16/2016 at 11:40 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #4. This room contained a smoke detector with in three feet of an air diffuser.

6. Observation and interview on 08/16/2016 at 11:49 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #9. This room contained a smoke detector with in three feet of an air diffuser.

7. Observation and interview on 08/16/2016 at 11:50 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #10. This room contained a smoke detector with in three feet of an air diffuser.

8. Observation and interview on 08/16/2016 at 11:54 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #11. This room contained a smoke detector with in three feet of an air diffuser.

9. Observation and interview on 08/16/2016 at 11:56 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #12. This room contained a smoke detector with in three feet of an air diffuser.

10. Observation and interview on 08/16/2016 at 11:57 a.m., revealed the facility failed to maintain the corridor near Patient Room #11. This corridor contained a smoke detector with in three feet of an air diffuser.

11. Observation and interview on 08/16/2016 at 11:59 a.m., revealed the facility failed to maintain the corridor near Patient Room #14. This corridor contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all the residents and staff. This facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview of the mini blinds in the Conference Report Room on 08/16/2016 at 11:45 a.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Maintenance Director 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, placing all Staff in this room at risk in the event of a fire. The facility had a capacity of 25 and a census of 5.

Findings Include:

1. Observation and interview on 08/16/2016 at 10:50 a.m., revealed the facility failed to maintain the electrical system in the X-Ray Work Room. This room contained a surge protector supplying power to a fan.

2. Observation and interview on 08/16/2016 at 11:00 a.m., revealed the facility failed to maintain the electrical system in the Lab Office. This room contained a surge protector supplying power to a microwave and coffee maker.

3. Observation and interview on 08/16/2016 at 11:30 a.m., revealed the facility failed to maintain the electrical system in the On Call Room #2. This room contained an extension cord supplying power to a surge protector and fan. The Maintenance
Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the five smoke compartments in the building. This deficient practice could affect 5 residents, staff and visitors. The facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 08/16/2016 at 11:15 a.m., revealed the facility failed to maintain the lower level smoke barrier doors near Conference Room #2. These double doors failed to close and positively latch while being tested. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain a directional exit sign at the end of the corridor for one of ten exits. This deficient practice affects 5 residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 08/16/2016 at 11:35 a.m., revealed the facility failed to maintain a directional exit sign in the Emergency Room corridor near exam room
#3. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Maintenance Director verified this observation at the time of the survey process.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 5.

Findings include:

Review of the facility's fire drill records on 08/16/2016 at 11:32 a.m., revealed the facility failed to conduct at least one fire drill per shift per quarter of 2015. The facility failed to provide documentation of any fire drills being conducted on the second or third shift , third quarter of 2015. The facility failed to provide documentation for any drills on the third shift fourth quarter 2015. The Maintenance Director verified this through record review 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 NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 5 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 5.

Findings include:

1. Observation and interview on 08/16/2016 at 10:45 a.m., revealed the facility failed to maintain the Fire Alarm System in the the Central Supply Storage Room. This room contained a smoke detector with in three feet of an air diffuser.

2. Observation and interview on 08/16/2016 at 11:36 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #1. This room contained a smoke detector with in three feet of an air diffuser.

3. Observation and interview on 08/16/2016 at 11:37 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #2. This room contained a smoke detector with in three feet of an air diffuser.

4. Observation and interview on 08/16/2016 at 11:38 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #3. This room contained a smoke detector with in three feet of an air diffuser.

5. Observation and interview on 08/16/2016 at 11:40 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #4. This room contained a smoke detector with in three feet of an air diffuser.

6. Observation and interview on 08/16/2016 at 11:49 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #9. This room contained a smoke detector with in three feet of an air diffuser.

7. Observation and interview on 08/16/2016 at 11:50 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #10. This room contained a smoke detector with in three feet of an air diffuser.

8. Observation and interview on 08/16/2016 at 11:54 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #11. This room contained a smoke detector with in three feet of an air diffuser.

9. Observation and interview on 08/16/2016 at 11:56 a.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #12. This room contained a smoke detector with in three feet of an air diffuser.

10. Observation and interview on 08/16/2016 at 11:57 a.m., revealed the facility failed to maintain the corridor near Patient Room #11. This corridor contained a smoke detector with in three feet of an air diffuser.

11. Observation and interview on 08/16/2016 at 11:59 a.m., revealed the facility failed to maintain the corridor near Patient Room #14. This corridor contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all the residents and staff. This facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview of the mini blinds in the Conference Report Room on 08/16/2016 at 11:45 a.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Maintenance Director 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, placing all Staff in this room at risk in the event of a fire. The facility had a capacity of 25 and a census of 5.

Findings Include:

1. Observation and interview on 08/16/2016 at 10:50 a.m., revealed the facility failed to maintain the electrical system in the X-Ray Work Room. This room contained a surge protector supplying power to a fan.

2. Observation and interview on 08/16/2016 at 11:00 a.m., revealed the facility failed to maintain the electrical system in the Lab Office. This room contained a surge protector supplying power to a microwave and coffee maker.

3. Observation and interview on 08/16/2016 at 11:30 a.m., revealed the facility failed to maintain the electrical system in the On Call Room #2. This room contained an extension cord supplying power to a surge protector and fan. The Maintenance
Director verified these observations at the time of the survey process.