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Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the fourteen smoke compartments in the building. One of the smoke compartments contains the main dining room and kitchen and could affect patients, vistors and staff in this zone. The facility has 25 certified beds.

Findings include:

Observation and interview on 4/5/12, revealed while testing the fire alarm system, one out of three smoke doors in the Kitchen area did not close properly. Maintenance Staff confirmed these 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 affected one of fourteen smoke compartments, (basement level). This facility is certified for 25 beds.

Findings include:

1. Observation and interview of the basement Electrical/phone room and three storage rooms on 4/5/12, revealed that the doors to the corridor did not have self closing devices.
2. Observation and interview of the Electrical /phone room on 4/5/12, revealed the room walls had penetration and holes ranging from 1/2 inch to 8 inch.

Maintenance Staff verified these 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 one of fourteen smoke compartments, (basement level). This facility is certified for 25 beds.

Findings include:

Observation and interview on 4/5/12 revealed, the following rooms contained holes and penetrations;

1. The Air Handler Room had a 6 inch x 8 inch hole in the ceiling of the NE corner.
2. The Pump Room had two 1/2 inch pipe penetrations.

Maintenance Staff verified these observation during the survey process.

Based on observation and record review, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility is certified for 25 beds.

Findings include:

Observation and record review of the facility ' s fire drill records on 4/5/12, revealed that three of four quarters had missing fire drills on various shifts. The 2nd quarter was missing the the night shift drill, 3rd quarter was missing the day shift drill and 3rd quarter was missing the evening shift drill. Maintenance Staff verified this observation 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 patients. This facility is certified for 25 beds.

Findings include:

Observation and interview on 4/5/12, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker (ELS 15 & 17) 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.

(A)
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. This facility is certified for 25 beds.

Findings include:

Observation and interview on 4/5/12, revealed the following areas had air supplies within three feet of the smoke detectors: X-ray room, Gift shop and Lab area. Maintenance Staff verified the observations during the survey process.

(B)
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 fourteen smoke compartments. The facility is certified for 25 beds.

Findings include:

Observation and record review of the inspection records for the fire alarm system on 4/05/12, revealed that the last inspection was completed on 8/25/11 by an outside certified company and a semi annual inspection has not been completed. Maintenance Staff verified this observation at the time of the survey.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. Standard for the installation of Sprinkler Systems, 1999 edition. The facility is certified for 25 beds.

Findings include:

Observation and interview on 4/05/12, revealed the main/old elevator shaft was not sprinklered. There were 2 seperate shafts and 1 was sprinkled and 1 was not. Both serve the same floors. Maintenance Staff verified this observation during the survey process.

(A)
Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place one of fourteen smoke compartments. The facility is certified for 25 beds.

Findings include:

Observation and staff interview on 4/5/12, the sprinkler heads located in the Clean workroom had dust covering the arms and deflectors. This observation was verified with Maintenance Staff during the survey process.

(B)
Based on observation, staff interview and record review, the facility failed to maintain the automatic sprinkler system. All smoke compartments, patients, visitors, and staff could be affected by the deficient practice. The facility has 25 certified beds.

Findings include:

Observation, staff interview and record review of the facilities fire safety components on 4/5/12, revealed no quarterly inspection had been conducted. Maintenance Staff confirmed this observation during the survey process.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system. The facility also had two different types of sprinkler heads (quick response and standard) located within the same compartment. This would affect one out of fourteen smoke compartments. This facility has 25 certified beds.

Findings include:

Observation and interview on 4/5/12, revealed the new addition wing at the Nurse's Station had mixed quick response and standard response sprinkler heads within the same compartment. Maintenance Staff verified this observation at the time of the survey.

Based on observation and interview, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. The facility kitchen area is located in one of fourteen smoke compartments in the building. The facility has 25 certified beds.

Findings include:

Observation and interview on 4/5/12, during the interview with the facility maintenance staff, it was observed, that the kitchen suppression system had not been inspected since 8/25/11 by an outside company. They were missing a semi- annual inspection. Maintenance Staff confirmed observations during the survey process.

Based on observation and staff interview, the facility did not assure that the smoke dampers located in the main building to be operable to prevent the passage of smoke and fire to another smoke zone. This deficient practice effects the occupants of all smoke zones, including staff, visitors and residents, who may need to use these areas as a safe zone in the event of an emergency. This facility is certified for 25 beds.

Findings include:

Observation and interview on 4/5/12, revealed the smoke dampers had not been inspected in accordance with NFPA 90A 3-4.7 1999 Edition. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility failed to maintain the paperwork of the emergency generator power supply as required. The deficient practice would affect all smoke compartments of building and all of the residents and staff. The facility has 25 certified beds.

Findings include:

Observation and interview on 4/5/12, revealed that proper documentation of the generator monthly inspections did not provide the start and end run times. Maintenance Staff verified this observation during the survey process.

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 patients of the facility at risk in the event of a fire. The facility is certified for 25 beds.

Findings Include:

Observation and interview on 4/05/12, revealed the facility failed to maintain the directory for electrical panel labeled LN1E. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the fourteen smoke compartments in the building. One of the smoke compartments contains the main dining room and kitchen and could affect patients, vistors and staff in this zone. The facility has 25 certified beds.

Findings include:

Observation and interview on 4/5/12, revealed while testing the fire alarm system, one out of three smoke doors in the Kitchen area did not close properly. Maintenance Staff confirmed these 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 affected one of fourteen smoke compartments, (basement level). This facility is certified for 25 beds.

Findings include:

1. Observation and interview of the basement Electrical/phone room and three storage rooms on 4/5/12, revealed that the doors to the corridor did not have self closing devices.
2. Observation and interview of the Electrical /phone room on 4/5/12, revealed the room walls had penetration and holes ranging from 1/2 inch to 8 inch.

Maintenance Staff verified these 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 one of fourteen smoke compartments, (basement level). This facility is certified for 25 beds.

Findings include:

Observation and interview on 4/5/12 revealed, the following rooms contained holes and penetrations;

1. The Air Handler Room had a 6 inch x 8 inch hole in the ceiling of the NE corner.
2. The Pump Room had two 1/2 inch pipe penetrations.

Maintenance Staff verified these observation during the survey process.

Based on observation and record review, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility is certified for 25 beds.

Findings include:

Observation and record review of the facility ' s fire drill records on 4/5/12, revealed that three of four quarters had missing fire drills on various shifts. The 2nd quarter was missing the the night shift drill, 3rd quarter was missing the day shift drill and 3rd quarter was missing the evening shift drill. Maintenance Staff verified this observation 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 patients. This facility is certified for 25 beds.

Findings include:

Observation and interview on 4/5/12, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker (ELS 15 & 17) 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.

(A)
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. This facility is certified for 25 beds.

Findings include:

Observation and interview on 4/5/12, revealed the following areas had air supplies within three feet of the smoke detectors: X-ray room, Gift shop and Lab area. Maintenance Staff verified the observations during the survey process.

(B)
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 fourteen smoke compartments. The facility is certified for 25 beds.

Findings include:

Observation and record review of the inspection records for the fire alarm system on 4/05/12, revealed that the last inspection was completed on 8/25/11 by an outside certified company and a semi annual inspection has not been completed. Maintenance Staff verified this observation at the time of the survey.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. Standard for the installation of Sprinkler Systems, 1999 edition. The facility is certified for 25 beds.

Findings include:

Observation and interview on 4/05/12, revealed the main/old elevator shaft was not sprinklered. There were 2 seperate shafts and 1 was sprinkled and 1 was not. Both serve the same floors. Maintenance Staff verified this observation during the survey process.

(A)
Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place one of fourteen smoke compartments. The facility is certified for 25 beds.

Findings include:

Observation and staff interview on 4/5/12, the sprinkler heads located in the Clean workroom had dust covering the arms and deflectors. This observation was verified with Maintenance Staff during the survey process.

(B)
Based on observation, staff interview and record review, the facility failed to maintain the automatic sprinkler system. All smoke compartments, patients, visitors, and staff could be affected by the deficient practice. The facility has 25 certified beds.

Findings include:

Observation, staff interview and record review of the facilities fire safety components on 4/5/12, revealed no quarterly inspection had been conducted. Maintenance Staff confirmed this observation during the survey process.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system. The facility also had two different types of sprinkler heads (quick response and standard) located within the same compartment. This would affect one out of fourteen smoke compartments. This facility has 25 certified beds.

Findings include:

Observation and interview on 4/5/12, revealed the new addition wing at the Nurse's Station had mixed quick response and standard response sprinkler heads within the same compartment. Maintenance Staff verified this observation at the time of the survey.

Based on observation and interview, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. The facility kitchen area is located in one of fourteen smoke compartments in the building. The facility has 25 certified beds.

Findings include:

Observation and interview on 4/5/12, during the interview with the facility maintenance staff, it was observed, that the kitchen suppression system had not been inspected since 8/25/11 by an outside company. They were missing a semi- annual inspection. Maintenance Staff confirmed observations during the survey process.

Based on observation and staff interview, the facility did not assure that the smoke dampers located in the main building to be operable to prevent the passage of smoke and fire to another smoke zone. This deficient practice effects the occupants of all smoke zones, including staff, visitors and residents, who may need to use these areas as a safe zone in the event of an emergency. This facility is certified for 25 beds.

Findings include:

Observation and interview on 4/5/12, revealed the smoke dampers had not been inspected in accordance with NFPA 90A 3-4.7 1999 Edition. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility failed to maintain the paperwork of the emergency generator power supply as required. The deficient practice would affect all smoke compartments of building and all of the residents and staff. The facility has 25 certified beds.

Findings include:

Observation and interview on 4/5/12, revealed that proper documentation of the generator monthly inspections did not provide the start and end run times. Maintenance Staff verified this observation during the survey process.

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 patients of the facility at risk in the event of a fire. The facility is certified for 25 beds.

Findings Include:

Observation and interview on 4/05/12, revealed the facility failed to maintain the directory for electrical panel labeled LN1E. Maintenance Staff verified this observation during the survey process.