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Based on observation and staff interviews the facility failed to maintain smoke and fire barrier doors in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was seven (7).

Findings include:

1. An observation on 01/14/20 at approximately 02:05 p.m. revealed a set of ninety (90) minute rated corridor doors missing floor strike plates by the lobby.

2. An interview on 01/14/20 at approximately 4:00 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the administrator at the exit interview on 01/14/20.

Based on record review and staff interviews the facility failed to ensure that fire drills were held at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was seven (7).

Findings include:

1. Record review on 01/13/20 at approximately 3:00 p.m. revealed fire drills recorded during the second shift of the first quarter at 4:02 p.m. and the second shift of the second quarter at 4:50 p.m., which were held within one (1) hour of each other.

2. Record review on 01/13/20 at approximately 3:00 p.m. revealed fire drills recorded during the third shift of the first quarter at 5:53 a.m. and the third shift of the second quarter at 5:30 a.m., which were held within one (1) hour of each other.

3. Record review on 01/13/20 at approximately 3:00 p.m. revealed the facility failed to record any fire drills for the fourth quarter of 2019.

4. An interview on 01/14/20 at approximately 2:15 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the administrator at the exit interview on 01/14/20.

Based on record review and staff interviews the facility failed to conduct maintenance and testing on the facility essential electric system in accordance with National Fire Protection Association (NFPA) 110. The facility's census was seven (7).

Findings include:

1. Facility document review on 01/13/20 at approximately 3:00 p.m. revealed no documentation of an annual fuel quality test for the generator.

2. An interview on 01/14/20 at approximately 2:15 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the administrator at the exit interview on 01/14/20.

Based on observation and staff interviews the facility failed to maintain electrical equipment testing and maintenance in accordance with National Fire Protection Association (NFPA) 101 and 99. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census was seven (7).

Findings include:

1. A facility tour conducted on 01/14/19 at 1:46 p.m. revealed no evidence of the physical integrity, resistance, leakage current and tough current tests for fixed and portable patient-care related electrical equipment for the patient beds.

2. An interview on 01/14/20 at approximately 2:15 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the administrator at the exit interview on 01/14/20.