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Based on observation and interview, the facility failed to maintain smoke resistance in hazardous areas. Failure to maintain these hazardous areas smoke tight put 4 patients of the facility in one of seven smoke zones at risk should a fire develop in the hazard areas because of the spread of smoke. Census was 8.

Findings are:

1. Observation on 1-7-16 at 10:35 am revealed the door to the North Nursing Storage room was not provided with an automatic door closure.

During interview on 01-07-16 at 10:35 am, Maintenance A confirmed the lack of the door closure.

2. Observtion on 1-7016 at 10:56 AM., revealed the ceiling in the Wheel chair storage had openings around the duct and pipes that failed to be sealed.

During interview on 01-07-16 at 10:56 am, Maintenance A confirmed there were unsealed openings around the ducts and pipes in the ceiling.

Based on record review and interview, the facility failed to document and conduct fire drills under varied conditions at different times of the day for two of four quarters reviewed. This had the potential to affect staff preparation and experience in providing for the protection of all patients in the event of a fire. Census was 8.

Findings are:

Record review on 01-07-16 at 12:35 PM of fire drill documentation showed that the facility had not conducted all the fire drills in each quarter for each shift. The facility filed to conduct the 3rd quarter drill on Day shift and the 4th quarter drill on Night shift. Both shifts had some drills less than an hour difference from any previous ones for that shift..

Interview at 12:35 PM on 01-07-16 with Maintenance A confirmed the lack of drills and the drills not all random times.

Record review of the following NFPA Standard revealed: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2

Based on observation and interview, the facility failed to maintain smoke resistance in hazardous areas. Failure to maintain these hazardous areas smoke tight put 4 patients of the facility in one of seven smoke zones at risk should a fire develop in the hazard areas because of the spread of smoke. Census was 8.

Findings are:

1. Observation on 1-7-16 at 10:35 am revealed the door to the North Nursing Storage room was not provided with an automatic door closure.

During interview on 01-07-16 at 10:35 am, Maintenance A confirmed the lack of the door closure.

2. Observtion on 1-7016 at 10:56 AM., revealed the ceiling in the Wheel chair storage had openings around the duct and pipes that failed to be sealed.

During interview on 01-07-16 at 10:56 am, Maintenance A confirmed there were unsealed openings around the ducts and pipes in the ceiling.

Based on record review and interview, the facility failed to document and conduct fire drills under varied conditions at different times of the day for two of four quarters reviewed. This had the potential to affect staff preparation and experience in providing for the protection of all patients in the event of a fire. Census was 8.

Findings are:

Record review on 01-07-16 at 12:35 PM of fire drill documentation showed that the facility had not conducted all the fire drills in each quarter for each shift. The facility filed to conduct the 3rd quarter drill on Day shift and the 4th quarter drill on Night shift. Both shifts had some drills less than an hour difference from any previous ones for that shift..

Interview at 12:35 PM on 01-07-16 with Maintenance A confirmed the lack of drills and the drills not all random times.

Record review of the following NFPA Standard revealed: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2