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Based upon observation and staff interview, the facility fails to assure that interior finish for corridors and exitways has a flame spread rating of Class A or Class B. The deficient practice would allow for flame to spread rapidly across the surface of the exposed wood treatment, affecting 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., it is observed that a portion of the nurses' station has a finish consisting of wood laminate plywood. No documentation was available reflecting the flame spread rating of the exposed surface.

Staff A was present, acknowledged the presence of the wood surface and stated that he did know the flame spread rating of the material.

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 has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., a review of records revealed the following:

-- 1. Fire drills are conducted within close proximity of each other:
a. Fire Drills for the 1st Shift, 2nd Qtr 2009, 3rd Qtr 2009 and 4th Qtr 2009, were held at 1:00 p.m. 1:45 p.m. and 2:10 p.m., respectively.
b. Fire Drills for the 2nd Shift, 2nd Qtr 2009, 3rd Qtr 2009 and 4th Qtr 2009, were held at 3:15 p.m., 4:45 p.m. and 4:00 p.m., respectively.
c. Fire Drills for the 3rd Shift, 2nd Qtr 2009, 4th Qtr 2009 and 1st Qtr 2010, were held at 12:00 a.m., 11:50 p.m. and 12:30 a.m., respectively.

Staff A was present and acknowledged the results of the record review.

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., it is observed that charting workstations and chairs are stored in the corridor near rooms 105 and 115.

Staff A was present, acknowledged the presence of the workstations and chairs and acknowledged that the items should not be stored in the corridor.

Based upon observation and staff interview, the facility fails to provide a remote annunciator for the generator in a continuously monitored location in accordance with NFPA 99 and NFPA 110. The deficient practice would not give staff sufficient notification of a potential generator failure. The deficient practice affects 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., it is observed that the facility's remote annunciator is located in a mechanical room which is not continuously attended. No audible and visual derangement signal is established in a continuously monitored location.

Staff A was present and acknowledged that generator's remote annunciator is located in a space periodically unattended.

Based on observation and staff interview, the facility fails to assure that electrical wiring in a wet location is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., it is observed that electrical outlets near a sink in the Emergency Room are not protected by a G.F.C.I. breakers.

Staff A was present and acknowledged that the outlets are not protected.

Based upon observation and staff interview, the facility fails to assure that interior finish for corridors and exitways has a flame spread rating of Class A or Class B. The deficient practice would allow for flame to spread rapidly across the surface of the exposed wood treatment, affecting 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., it is observed that a portion of the nurses' station has a finish consisting of wood laminate plywood. No documentation was available reflecting the flame spread rating of the exposed surface.

Staff A was present, acknowledged the presence of the wood surface and stated that he did know the flame spread rating of the material.

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 has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., a review of records revealed the following:

-- 1. Fire drills are conducted within close proximity of each other:
a. Fire Drills for the 1st Shift, 2nd Qtr 2009, 3rd Qtr 2009 and 4th Qtr 2009, were held at 1:00 p.m. 1:45 p.m. and 2:10 p.m., respectively.
b. Fire Drills for the 2nd Shift, 2nd Qtr 2009, 3rd Qtr 2009 and 4th Qtr 2009, were held at 3:15 p.m., 4:45 p.m. and 4:00 p.m., respectively.
c. Fire Drills for the 3rd Shift, 2nd Qtr 2009, 4th Qtr 2009 and 1st Qtr 2010, were held at 12:00 a.m., 11:50 p.m. and 12:30 a.m., respectively.

Staff A was present and acknowledged the results of the record review.

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., it is observed that charting workstations and chairs are stored in the corridor near rooms 105 and 115.

Staff A was present, acknowledged the presence of the workstations and chairs and acknowledged that the items should not be stored in the corridor.

Based upon observation and staff interview, the facility fails to provide a remote annunciator for the generator in a continuously monitored location in accordance with NFPA 99 and NFPA 110. The deficient practice would not give staff sufficient notification of a potential generator failure. The deficient practice affects 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., it is observed that the facility's remote annunciator is located in a mechanical room which is not continuously attended. No audible and visual derangement signal is established in a continuously monitored location.

Staff A was present and acknowledged that generator's remote annunciator is located in a space periodically unattended.

Based on observation and staff interview, the facility fails to assure that electrical wiring in a wet location is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 10 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 04/27/2010, between 1:00 p.m. and 4:30 p.m., it is observed that electrical outlets near a sink in the Emergency Room are not protected by a G.F.C.I. breakers.

Staff A was present and acknowledged that the outlets are not protected.