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Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two (2) of fifteen (15) smoke compartments and could affect approximately 10-15 staff as well as residents and visitors. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

1. Observation and interview of the Soiled Laundry Room on 06/13/11 at 10:05 a.m.; revealed that the west masonry wall was penetrated by two (2) electrical conduits. These penetrations had a 1/4 to 1/2 inch gap around the conduit. All other penetrations in this room were sealed.

2. Observations and interview of the Kitchen on 06/13/11 and 10:12 a.m.; revealed the ceiling was not intact and the one (1) hour rating of the room was not met. There were nine (9) of seventeen (17) sprinkler heads that had gaps at the ceiling. These ranged from 1/4 inch to 1/2 inch in size

Maintenance Staff A confirmed these observations.

Based on observation and interview, the facility failed to provide a directional exit sign in one (1) zone of the facility. This deficient practice effects residents, staff and visitors in the Surgery/Physical Therapy corridor of this facility. This facility is licensed for 25 and a census of 8.

Findings Include

Observations and interview on 06/13/11 at 11:07 a.m., revealed the Surgery/Physical Therapy corridor was missing an exit sign. When the smoke doors next to Physical Therapy were open a sign could be seen at the end of the hallway. When the Fire Alarm was activated and the doors closed there was no Exit sign visible leading to the Fire Exit. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to conduct fire drills at varied times during the year 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 8 residents.

Findings include:

Review of the facility's fire drill records on 06/13/11, revealed that fire drills were conducted with in an hour of each other on the Evening and Night shifts. The Evening Shift (3p-11p) were completed at the following times: 02/17/11 at 7:37 p.m., 05/08/11 at 8:50 p.m., 09/01/10 at 4:06 p.m. and 11/30/10 at 3:57 p.m. The Night Shift (11a-7p) were completed at the following times: 03/09/11 at 6:20 a.m., 06/22/10 at 5:35 a.m., 09/30/10 at 5:05 a.m. and 12/15/10 at 4:49 a.m.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 8.

Findings include:

Observations and interview on 06/13/11 at 11:59 a.m. revealed, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in Electric Panel BEA #22 next to the Fire Alarm Panel was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff A verified this observation.

Based on observation and interview, it was determined 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 the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 8 at the time of the survey.

Findings Include:

1. Observations and interview on 06/13/11 at 10:09 a.m., revealed the facility failed to maintain the electrical system in the Boiler Room. Behind the sprinkler riser there were three (3) open junction boxes along the West and North wall. These either were missing the cover plates or had the cover plates open exposing electrical wires and wire nuts.
2. Observations and interview on 06/13/11 at 10:48 a.m., revealed the two (2) microwaves in the Dining Area (on cart) were both plugged into a surge protector and then into the wall.
3. Observations and interview on 06/13/11 at 12:01 p.m., reveled the Reception Office had a fan plugged into a surge protector. This device was unplugged and plugged into the wall while this inspector was present.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two (2) of fifteen (15) smoke compartments and could affect approximately 10-15 staff as well as residents and visitors. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

1. Observation and interview of the Soiled Laundry Room on 06/13/11 at 10:05 a.m.; revealed that the west masonry wall was penetrated by two (2) electrical conduits. These penetrations had a 1/4 to 1/2 inch gap around the conduit. All other penetrations in this room were sealed.

2. Observations and interview of the Kitchen on 06/13/11 and 10:12 a.m.; revealed the ceiling was not intact and the one (1) hour rating of the room was not met. There were nine (9) of seventeen (17) sprinkler heads that had gaps at the ceiling. These ranged from 1/4 inch to 1/2 inch in size

Maintenance Staff A confirmed these observations.

Based on observation and interview, the facility failed to provide a directional exit sign in one (1) zone of the facility. This deficient practice effects residents, staff and visitors in the Surgery/Physical Therapy corridor of this facility. This facility is licensed for 25 and a census of 8.

Findings Include

Observations and interview on 06/13/11 at 11:07 a.m., revealed the Surgery/Physical Therapy corridor was missing an exit sign. When the smoke doors next to Physical Therapy were open a sign could be seen at the end of the hallway. When the Fire Alarm was activated and the doors closed there was no Exit sign visible leading to the Fire Exit. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to conduct fire drills at varied times during the year 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 8 residents.

Findings include:

Review of the facility's fire drill records on 06/13/11, revealed that fire drills were conducted with in an hour of each other on the Evening and Night shifts. The Evening Shift (3p-11p) were completed at the following times: 02/17/11 at 7:37 p.m., 05/08/11 at 8:50 p.m., 09/01/10 at 4:06 p.m. and 11/30/10 at 3:57 p.m. The Night Shift (11a-7p) were completed at the following times: 03/09/11 at 6:20 a.m., 06/22/10 at 5:35 a.m., 09/30/10 at 5:05 a.m. and 12/15/10 at 4:49 a.m.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 8.

Findings include:

Observations and interview on 06/13/11 at 11:59 a.m. revealed, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in Electric Panel BEA #22 next to the Fire Alarm Panel was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff A verified this observation.

Based on observation and interview, it was determined 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 the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 8 at the time of the survey.

Findings Include:

1. Observations and interview on 06/13/11 at 10:09 a.m., revealed the facility failed to maintain the electrical system in the Boiler Room. Behind the sprinkler riser there were three (3) open junction boxes along the West and North wall. These either were missing the cover plates or had the cover plates open exposing electrical wires and wire nuts.
2. Observations and interview on 06/13/11 at 10:48 a.m., revealed the two (2) microwaves in the Dining Area (on cart) were both plugged into a surge protector and then into the wall.
3. Observations and interview on 06/13/11 at 12:01 p.m., reveled the Reception Office had a fan plugged into a surge protector. This device was unplugged and plugged into the wall while this inspector was present.

Maintenance Staff A verified these observations.