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Based on observation and interview, the facility failed to maintain 1 set of smoke barrier doors to close properly. This affects 2 of 8 smoke zones, affecting approximately 2 residents and 5 staff members. The facility had a capacity of 25 patients and census of 3 patients.

Findings include:

Observation and interview on 8-13-15 at approximately 11:26 am, revealed the smoke barrier doors located near Patient Room #405 failed to close and latch properly when tested.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain 2 hazardous rooms properly separated by allowing the doors to these rooms to be non-compliant. This affects 2 of 8 smoke zones, affecting 5 staff members only due to the fact that the deficiency occurred in a non-patient area. The facility had a license capacity of 25 patients and a census of 3 patients.

Findings include:

Observations and interview on 8-13-15 at approximately 10:38 am and 11:00 am, revealed the following:

1. The door to the Janitor's Closet located at the bottom of the ramp in the Basement failed to close and latch properly when tested.

2. The door to the Acute Care Equipment Storage Room located in the Basement failed to close and latch properly when tested.

Maintenance Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition by improperly locating 3 smoke detectors. This would affect 3 of 8 smoke zones, affecting 1 resident and 6 staff members. The facility had a license of 25 patients and a census of 3 patients.

Findings include:

Observations and interview on 8-13-15 at approximately 10:46 am, 11:24 am and 11:55 am revealed the following:

1. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Conference Room in the Basement.

2. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of Patient Room #409.

3. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Accounting Office.

Maintenance Staff A verified these observations during the survey process.

Based on observations and interview, the facility failed to ensure the buildings 2 emergency generators were properly equipped with a remote manual stop mechanism, in accordance with National Fire Protection Association (NFPA) 110, 1999 Edition. This affects all 8 smoke zones, affecting all occupants within the facility. The facility had a license of 25 patients and a census of 3 patients.

Finding include:

Observations and interview on 8-13-15 at approximately 11:45 am, revealed the facilities 2 emergency generators were not equipped with a remote manual stop mechanism (emergency shut-off). This remote manual stop mechanism shall be in place somewhere near the emergency generator, but not inside the generators main panel or inside the room that houses the generator.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain 1 set of smoke barrier doors to close properly. This affects 2 of 8 smoke zones, affecting approximately 2 residents and 5 staff members. The facility had a capacity of 25 patients and census of 3 patients.

Findings include:

Observation and interview on 8-13-15 at approximately 11:26 am, revealed the smoke barrier doors located near Patient Room #405 failed to close and latch properly when tested.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain 2 hazardous rooms properly separated by allowing the doors to these rooms to be non-compliant. This affects 2 of 8 smoke zones, affecting 5 staff members only due to the fact that the deficiency occurred in a non-patient area. The facility had a license capacity of 25 patients and a census of 3 patients.

Findings include:

Observations and interview on 8-13-15 at approximately 10:38 am and 11:00 am, revealed the following:

1. The door to the Janitor's Closet located at the bottom of the ramp in the Basement failed to close and latch properly when tested.

2. The door to the Acute Care Equipment Storage Room located in the Basement failed to close and latch properly when tested.

Maintenance Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition by improperly locating 3 smoke detectors. This would affect 3 of 8 smoke zones, affecting 1 resident and 6 staff members. The facility had a license of 25 patients and a census of 3 patients.

Findings include:

Observations and interview on 8-13-15 at approximately 10:46 am, 11:24 am and 11:55 am revealed the following:

1. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Conference Room in the Basement.

2. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of Patient Room #409.

3. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Accounting Office.

Maintenance Staff A verified these observations during the survey process.

Based on observations and interview, the facility failed to ensure the buildings 2 emergency generators were properly equipped with a remote manual stop mechanism, in accordance with National Fire Protection Association (NFPA) 110, 1999 Edition. This affects all 8 smoke zones, affecting all occupants within the facility. The facility had a license of 25 patients and a census of 3 patients.

Finding include:

Observations and interview on 8-13-15 at approximately 11:45 am, revealed the facilities 2 emergency generators were not equipped with a remote manual stop mechanism (emergency shut-off). This remote manual stop mechanism shall be in place somewhere near the emergency generator, but not inside the generators main panel or inside the room that houses the generator.

Maintenance Staff A verified this observation at the time of the survey process.