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Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of four smoke compartments and could affect patients, vistors and staff located in this smoke compartment. This facility has a capacity of 25 and a census of 2 patients.

Findings include:

1. Observation of the Laundry/Storage Room and Purchasing Room on 2/14/11, revealed that the doors were not equipped with self closing devices.
2. Observation of the Laundry/Storage Room on 2/14/11, revealed several penetrations; three metal conduits contained 1/2 inch penetrations and a 4 inch pipe contained a 1/2 inch penetration.
3. Observation of the Electrical Room on 2/14/11, revealed a 1 inch by 3 inch hole with metal conduit.

(A)
Based on observation and record review, the facility failed to provided a properly tested and maintained fire alarm system. All of the facility was directly affected by the deficient practice; a total of four smoke compartments and approximately 2 patients and staff members. The facility has 25 certified beds and at the time of the survey the census was 2.

Findings include:

Observation and review of the inspection records for the fire alarm system on 2/14/11, revealed that the inspection forms did not meet the NFPA 72 standards required.


(B)
Based on observation and record review, the facility failed to provided a properly maintained fire alarm system. All of the facility was directly affected by the deficient practice; two out of four smoke compartments and approximately 2 patients and staff members. The facility has 25 certified beds and at the time of the survey the census was 2.

Findings include:

Observation on 2/14/11, revealed that three pull stations were at approximately 5 feet and 6 inches above the floor at the following locations; Laundry Storage Room, by the two-hour wall, and the West hall. These pull stations are required to be between 3 1/2 feet to 4 1/2 feet above the floor according to NFPA 72 2-8.1.

Based on record review, the facility failed to provide the proper paperwork for the testing of the smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility census is 2 with a capacity of 25.

Findings include:

Record review on 2/14/11, showed a lack of information on the report; this report gave a list of ranges for smoke detectors, but did not know what ranges were operating within the sensitivity range set forth by the manufacturer for these specific detectors. The report did not show a pass/fail next to each of the detector.

Based on record review, the facility did not assure that the smoke dampers located in one of four smoke barriers was tested by an outside company assuring to be operable to prevent the passage of smoke and fire to another smoke zone. This deficient practice effects the occupants of two smoke zones, including staff, visitors and 2 patients, who may need to use these areas as a safe zone in the event of an emergency. This facility has a capacity of 25 and a census of 2 patients.

Record review of the fire alarm paperwork on 2/14/11, showed no indication that the smoke damper had been inspected as required by code.

Based on observation, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. The absence of a remote annunciator for the emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 2.

Findings include:

Observation on 2/14/11, revealed the absence of a remote annunciator panel (storage battery powered) for the emergency generator.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of four smoke compartments and could affect patients, vistors and staff located in this smoke compartment. This facility has a capacity of 25 and a census of 2 patients.

Findings include:

1. Observation of the Laundry/Storage Room and Purchasing Room on 2/14/11, revealed that the doors were not equipped with self closing devices.
2. Observation of the Laundry/Storage Room on 2/14/11, revealed several penetrations; three metal conduits contained 1/2 inch penetrations and a 4 inch pipe contained a 1/2 inch penetration.
3. Observation of the Electrical Room on 2/14/11, revealed a 1 inch by 3 inch hole with metal conduit.

(A)
Based on observation and record review, the facility failed to provided a properly tested and maintained fire alarm system. All of the facility was directly affected by the deficient practice; a total of four smoke compartments and approximately 2 patients and staff members. The facility has 25 certified beds and at the time of the survey the census was 2.

Findings include:

Observation and review of the inspection records for the fire alarm system on 2/14/11, revealed that the inspection forms did not meet the NFPA 72 standards required.


(B)
Based on observation and record review, the facility failed to provided a properly maintained fire alarm system. All of the facility was directly affected by the deficient practice; two out of four smoke compartments and approximately 2 patients and staff members. The facility has 25 certified beds and at the time of the survey the census was 2.

Findings include:

Observation on 2/14/11, revealed that three pull stations were at approximately 5 feet and 6 inches above the floor at the following locations; Laundry Storage Room, by the two-hour wall, and the West hall. These pull stations are required to be between 3 1/2 feet to 4 1/2 feet above the floor according to NFPA 72 2-8.1.

Based on record review, the facility failed to provide the proper paperwork for the testing of the smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility census is 2 with a capacity of 25.

Findings include:

Record review on 2/14/11, showed a lack of information on the report; this report gave a list of ranges for smoke detectors, but did not know what ranges were operating within the sensitivity range set forth by the manufacturer for these specific detectors. The report did not show a pass/fail next to each of the detector.

Based on record review, the facility did not assure that the smoke dampers located in one of four smoke barriers was tested by an outside company assuring to be operable to prevent the passage of smoke and fire to another smoke zone. This deficient practice effects the occupants of two smoke zones, including staff, visitors and 2 patients, who may need to use these areas as a safe zone in the event of an emergency. This facility has a capacity of 25 and a census of 2 patients.

Record review of the fire alarm paperwork on 2/14/11, showed no indication that the smoke damper had been inspected as required by code.

Based on observation, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. The absence of a remote annunciator for the emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 2.

Findings include:

Observation on 2/14/11, revealed the absence of a remote annunciator panel (storage battery powered) for the emergency generator.