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Based on observation and staff interview, the facility failed to maintain corridors free of all obstructions to full use in case of emergency in accordance with NFPA (National Fire Protection Association) 101. Facility Census: Nine (9).

Findings include:

1. During the facility inspection tour on 09/12/17 between the hours of 1:00 p.m. and 4:00 p.m., the basement corridor next to the Medical Records and the corridor next to the Conference room were observed to be blocked with construction materials and furniture.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Supervisor on 09/13/17 at approximately 4:00 p.m. and agreed this deficiency needed corrected.

Based on observation and staff interview, during the facility document review, it was determined the facility failed to conduct annual checks of the battery powered emergency lights in accordance with NFPA (National Fire Protection Association) 101. Facility Census: Nine (9).

Findings include:

1. During the facility document review conducted on 09/12/17 between the hours of 10:00 a.m. and 3:00 p.m., it revealed the facility failed to conduct annual operational checks on battery powered emergency lights in accordance with NFPA 101.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Supervisor on 09/13/17 at approximately 4:00 p.m. and agreed this deficiency needed corrected.

Based on observation during the facility inspection tour, it revealed the facility failed to provide smoke resisting partitions in the basement kitchen storage room in accordance with NFPA (National Fire Protection Association) 101. Facility Census:Nine (9).

Findings include:

1. During the facility inspection tour on 09/12/17 between the hours of 1:00 p.m. and 4:00 p.m., it revealed the facility failed to provide smoke resisting partitions in the basement kitchen storage room in accordance with NFPA 101.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Supervisor on 09/13/17 at approximately 4:00 p.m. and agreed this deficiency needed corrected.

Based on observation and staff interview, during the facility document review, the facility failed to inspect and test the Automatic Sprinkler system in accordance with NFPA (National Fire Protection Association) 25. Facility Census: Nine (9).

Findings include:

1. During the facility document review on 09/12/17, between the hours of 10:00 a.m. and 1:00 p.m., it revealed the facility failed to conduct the 3rd quarter automatic sprinkler system inspection of 2017 as required by the NFPA 25.

2. During the facility inspection tour on 09/12/17 between the hours of 1:00 p.m. and 4:00 p.m. it revealed wires laying on top of the sprinkler piping above the corridor ceiling next to Purchasing, on the sprinkler piping in Purchasing and a rope tied to the sprinkler piping above the corridor ceiling next to the tunnel entrance.

3. During the facility inspection tour on 09/13/17 between the hours of 8:00 a.m. and 4:00 p.m. it revealed wires laying on top of the sprinkler piping on the first floor above the corridor ceiling next to the elevators, on the 3rd floor above the corridor ceiling next to room #305, on the 3rd floor above the corridor ceiling next to room #305 and on the 4th floor above the corridor ceiling next to room #417.

4. The aforementioned deficiency was discussed with the Administrator and the Maintenance Supervisor on 09/13/17 at approximately 4:00 p.m. and agreed this deficiency needed corrected.

Based on observation and staff interview, the facility failed to maintain the building in accordance with NFPA (National Fire Protection Association) 70. Facility Census: Nine (9).

Findings include:

1. During the facility inspection tour on 09/13/17 between the hours of 8:00 a.m. and 4:00 p.m., open electrical junction boxes were observed in the basement above the corridor ceiling next to Purchasing, on the 3rd floor above the corridor ceiling next to room #311, above the corridor ceiling next to room #319 and on the 4th floor above the corridor ceiling next to the file storage.

2. During the facility inspection tour on 09/12/13 between the hours of 1:00 p.m. and 4:00 p.m., an open electrical junction box and a missing cover plate were observed in the kitchen next to the toaster.

3. The aforementioned deficiency was discussed with the Administrator and the Maintenance Supervisor 09/13/17 at approximately 4:00 p.m. and agreed this deficiency needed corrected.

Based on observation and staff interview, the facility failed to conduct receptacle testing in accordance with NFPA (National Fire Protection Association) 99. Facility Census: Nine (9).

Findings include:

1. During the facility document review on 09/12/17 between the hours of 10:00 a.m. and 1:00 p.m., revealed the facility failed to conduct receptacle testing of receptacles located at patient bed locations in accordance with NFPA 99.

2. The aforementioned deficiency was discussed with the Administrator and the Maintenance Supervisor on 09/13/17 at approximately 4:00 p.m. and agreed this deficiency needed corrected.