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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 affects one of nineteen smoke compartments in the building. The facility has 49 certified beds and at the time of the survey the census was 8 residents.

Findings include:

Observation and staff interview of the Kitchen on 10/31/11, revealed that the window/door was not tied into the fire alarm system. According to Maintenance Staff, the window/door contains a chain link that is used to close the door. This is not tied into the fire alarm system. The Kitchen is in the same smoke zone as the Dining room and corridor. Maintenance Staff verified this observation during the survey process.

(A)
Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of nineteen smoke compartments. This facility has a capacity of 49 and a census of 8 residents.

Findings include:

Observation and interview of the Transfer room on 10/31/11, revealed that the room contained several penetrations:

1. There was a 1/2 inch penetration surrounding the three inch pipe located in the floor above the Chiller room.

2. There was a 1/2 inch penetration surrounding a 3 inch pipe in the ceiling above the electrical panel. Maintenance Staff confirmed these observations during the survey process.

(B)
Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of nineteen smoke compartments in the building. The facility has 49 certified beds and at the time of the survey the census was 8.

Findings include:

During observation and interview of the MRI air handling/oxygen room on 10/31/11, revealed that the door to the room was not equipped with a self closing device. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of three smoke compartments of the clinic, and could affect patients and staff.

Findings include:

Observation and interview of the Mechanical/Electrical room on 10/31/11, revealed the ceiling has several penetrations: 1/2 inch penetration surrounding an 1/2 inch pipe and 8 inch by 16 inch hole. Staff confirmed these observations during the survey process.

Based on observations and interview, the facility failed to provide doors that did not require multiple manipulations to open the doors from the inside of the room. This deficient practice could affect two of nineteen smoke zones and residents, staff and visitors in these zones. The facility has a capacity of 49 and a census of 8 residents.

Findings Include:

Observations and interview on 10/31/11, revealed the following areas had dead bolts added to them for security. The means to open these doors were by a paddle handle on the door with the dead bolt requiring a secondary manipulation to unlock and then exit the room: 2nd Floor Quality Measure Specialist Door, Quality Improvement office Door, and the Kitchen doors


Maintenance Staff verified these findings during the survey process.

Based upon observation and interview, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 49 with a census of 8.

Findings include:

Observation and interview on 10/31/11, the facility fire drill documentation showed that all of the third shift drills were conducted within the same hour for all four quarters. The 3rd quarter showed a missing drill for the 2nd shift.

Maintenance Staff verified this documentation during the survey process.

Based on observation and interview, the facility did not 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 49 with a census of 8.

Findings include:

Observation and interview on 10/31/11, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical 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 verified this observation at the time of the survey.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This could affect all occupants of the building in one of nineteen smoke zones. This facility has a capacity of 49 and a census of 8 residents.

Findings include:

Observation and interview on 10/31/11, revealed an air supply within three feet of the smoke detectors located in the small conference room.

Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility failed to prohibit the use of electric plastic surge protection devices within the facility without over current protection and properly use power strips. The location of deficient practice was located in one of nineteen smoke compartments affecting all of the residents in that compartment. The facility census was 49 with a capacity of 8.

Findings include:

Observation and interview on 10/31/11, a surge protector was observed to be in use for the appliances located in the Oncology office.

Maintenance Staff confirmed observations during the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of nineteen smoke compartments in the building. The facility has 49 certified beds and at the time of the survey the census was 8 residents.

Findings include:

Observation and staff interview of the Kitchen on 10/31/11, revealed that the window/door was not tied into the fire alarm system. According to Maintenance Staff, the window/door contains a chain link that is used to close the door. This is not tied into the fire alarm system. The Kitchen is in the same smoke zone as the Dining room and corridor. Maintenance Staff verified this observation during the survey process.

(A)
Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of nineteen smoke compartments. This facility has a capacity of 49 and a census of 8 residents.

Findings include:

Observation and interview of the Transfer room on 10/31/11, revealed that the room contained several penetrations:

1. There was a 1/2 inch penetration surrounding the three inch pipe located in the floor above the Chiller room.

2. There was a 1/2 inch penetration surrounding a 3 inch pipe in the ceiling above the electrical panel. Maintenance Staff confirmed these observations during the survey process.

(B)
Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of nineteen smoke compartments in the building. The facility has 49 certified beds and at the time of the survey the census was 8.

Findings include:

During observation and interview of the MRI air handling/oxygen room on 10/31/11, revealed that the door to the room was not equipped with a self closing device. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of three smoke compartments of the clinic, and could affect patients and staff.

Findings include:

Observation and interview of the Mechanical/Electrical room on 10/31/11, revealed the ceiling has several penetrations: 1/2 inch penetration surrounding an 1/2 inch pipe and 8 inch by 16 inch hole. Staff confirmed these observations during the survey process.

Based on observations and interview, the facility failed to provide doors that did not require multiple manipulations to open the doors from the inside of the room. This deficient practice could affect two of nineteen smoke zones and residents, staff and visitors in these zones. The facility has a capacity of 49 and a census of 8 residents.

Findings Include:

Observations and interview on 10/31/11, revealed the following areas had dead bolts added to them for security. The means to open these doors were by a paddle handle on the door with the dead bolt requiring a secondary manipulation to unlock and then exit the room: 2nd Floor Quality Measure Specialist Door, Quality Improvement office Door, and the Kitchen doors


Maintenance Staff verified these findings during the survey process.

Based upon observation and interview, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 49 with a census of 8.

Findings include:

Observation and interview on 10/31/11, the facility fire drill documentation showed that all of the third shift drills were conducted within the same hour for all four quarters. The 3rd quarter showed a missing drill for the 2nd shift.

Maintenance Staff verified this documentation during the survey process.

Based on observation and interview, the facility did not 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 49 with a census of 8.

Findings include:

Observation and interview on 10/31/11, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical 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 verified this observation at the time of the survey.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This could affect all occupants of the building in one of nineteen smoke zones. This facility has a capacity of 49 and a census of 8 residents.

Findings include:

Observation and interview on 10/31/11, revealed an air supply within three feet of the smoke detectors located in the small conference room.

Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility failed to prohibit the use of electric plastic surge protection devices within the facility without over current protection and properly use power strips. The location of deficient practice was located in one of nineteen smoke compartments affecting all of the residents in that compartment. The facility census was 49 with a capacity of 8.

Findings include:

Observation and interview on 10/31/11, a surge protector was observed to be in use for the appliances located in the Oncology office.

Maintenance Staff confirmed observations during the survey process.