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Based on observation and interview, it was determined the facility is a two-story building and consisted of Type II construction. The facility failed to assure minimum building construction requirements were maintained. These deficient practices could affect two of eight smoke zones. This facility has a capacity of 25 and at the time of the survey the census was 18.

Findings include:

1. Observation and interview on 10/16/12, revealed a gap (approximately 2 inches in size) around ductwork in the Sterilization Room.
2. Observation and interview on 10/16/12, revealed numerous holes and gaps around penetrations in the Sterilization Room.
3. Observation and interview on 10/16/12, revealed numerous gaps around conduit above the electrical panels in Electrical Room 137B.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly in their frames. This deficient practice affects occupants in one of eight smoke zones. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observations and interview on 10/16/12, revealed Meeting Room Doors 101, 102, and 103 did not latch properly when tested. Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The areas of deficient practice affects three of eight smoke zones. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

1. Observation and interview on 10/16/12, revealed a gap (approximately 1 inch in size) around copper piping above the door in the Utility Room (next to Room E 113).
2. Observation and interview on 10/16/12, revealed multiple holes in the ceiling throughout the entire area in the Utility Room (next to Room E 113).
3. Observation and interview on 10/16/12, revealed multiple gaps around metal conduit above the electrical conduit in Utility Room (next to Room E 113).
4. Observation and interview on 10/16/12, revealed the corridor door to the Clean Linen Room (next to Isolation Supplies) in Hall 2 did not close and latch properly when tested.
5. Observation and interview on 10/16/12, revealed the Storage Room at the end of Hall 1 was greater than 50 square feet, open to the corridor, and used for storage. This door did not contain a self-closing device on it as required.
6. Observation and interview on 10/16/12, revealed the Hall 1 Store Room (next to Room 5) did not close and latch properly when tested.


Maintenance Staff A verified these observations.

Based on observation and interview, the facility was using an exit enclosure (under the stairway) for the storage of items. This deficient practice could affect anyone using this stairway in the event of an emergency. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observations and interview on 10/16/12, revealed the Upper Level Stairway was being used as a storage area for the storage of tables, chairs and water bottles. Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not assuring that the exits are readily assessable at all times in accordance with 7.1. This deficient practice affects two of eight smoke zones. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observations and interview on 10/16/12, revealed that the hinged charting stations in the corridors of Patient Halls 1 & 2 did not automatically retract which would impede the exit corridors. Maintenance Staff A verified these observations.

(A)
Based on record review and staff interview, the facility is not conducting fire drills at varying conditions and times on each shift as required. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a 25 certified beds and a census of 18.

Findings include:

Record review and staff interview on 10/16/12, revealed the facility failed to vary the times of the fire drills on both first and second shifts throughout the last 12 months. All fire drills on 1st shift were held between the hours of 0807 and 0909. All fire drills on the 2nd shift were held between the hours of 1915 and 2040. Maintenance Staff A verified these observations.

(B)
Based on record review and staff interview, the facility is not properly documenting and performing the fire drills as required. Fire drill forms were incomplete and silent drills were held on 2nd and 3rd shifts and testing of the alarm the following day of the silent drills were not being performed. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a 25 certified beds and a census of 18.

Findings include:

1. Record review and staff interview on 10/16/12, revealed the facility had incomplete fire drill forms. Most of the sections had lines though them, just indicating the time and date of the drill with no other information available.
2. Record review and staff interview on 10/16/12, revealed the facility was only conducting live fire drills activating the fire alarm system on 1st shift only.
3. Record review and staff interview on 10/16/12, revealed the facility failed to test the fire alarm system the following day after silent drills to verify that the system is in proper working order and to verify that the system sends a signal to the monitoring company.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to properly label and protect the primary power supply for the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, 1999 edition, 1-5.2.5.2 . This deficiency affects all occupants of the building. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observation and interview on 10/16/12, revealed the circuit breaker for the fire alarms primary power located in Electrical Room 137B (Panel LS2, Breaker 21) was not properly labeled or mechanically protected. Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. This deficient practice affects one of eight smoke zones. This facility has 25 licensed beds and at the time of the survey the census was 18.

Findings include:

Observation and interview on 10/16/12 revealed a dust coated sprinkler head in Housekeeping Closet 137A. Maintenance Staff A verified this observation.

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. The deficient practice could affect one of eight smoke zones. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observation and interview on 10/16/12, revealed a missing junction box cover on the wall in the Utility Room (next to Room E 113). Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility is not assuring that a proper policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and patients. This facility has a 25 certified beds and at the time of the survey the census was 18.

Findings include:

While performing a record review the outage policy on 10/16/12, it was revealed that the facility did not have an outage policy in place for a sprinkler system outage. Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility is not assuring that a proper policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and patients. This facility has a 25 certified beds and at the time of the survey the census was 18.

Findings include:

While performing a record review the outage policy on 10/16/12, it was revealed that the facility did not have an outage policy in place for a fire alarm system outage. Maintenance Staff A verified this observation.

Based on observation and interview, it was determined the facility is a two-story building and consisted of Type II construction. The facility failed to assure minimum building construction requirements were maintained. These deficient practices could affect two of eight smoke zones. This facility has a capacity of 25 and at the time of the survey the census was 18.

Findings include:

1. Observation and interview on 10/16/12, revealed a gap (approximately 2 inches in size) around ductwork in the Sterilization Room.
2. Observation and interview on 10/16/12, revealed numerous holes and gaps around penetrations in the Sterilization Room.
3. Observation and interview on 10/16/12, revealed numerous gaps around conduit above the electrical panels in Electrical Room 137B.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly in their frames. This deficient practice affects occupants in one of eight smoke zones. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observations and interview on 10/16/12, revealed Meeting Room Doors 101, 102, and 103 did not latch properly when tested. Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The areas of deficient practice affects three of eight smoke zones. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

1. Observation and interview on 10/16/12, revealed a gap (approximately 1 inch in size) around copper piping above the door in the Utility Room (next to Room E 113).
2. Observation and interview on 10/16/12, revealed multiple holes in the ceiling throughout the entire area in the Utility Room (next to Room E 113).
3. Observation and interview on 10/16/12, revealed multiple gaps around metal conduit above the electrical conduit in Utility Room (next to Room E 113).
4. Observation and interview on 10/16/12, revealed the corridor door to the Clean Linen Room (next to Isolation Supplies) in Hall 2 did not close and latch properly when tested.
5. Observation and interview on 10/16/12, revealed the Storage Room at the end of Hall 1 was greater than 50 square feet, open to the corridor, and used for storage. This door did not contain a self-closing device on it as required.
6. Observation and interview on 10/16/12, revealed the Hall 1 Store Room (next to Room 5) did not close and latch properly when tested.


Maintenance Staff A verified these observations.

Based on observation and interview, the facility was using an exit enclosure (under the stairway) for the storage of items. This deficient practice could affect anyone using this stairway in the event of an emergency. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observations and interview on 10/16/12, revealed the Upper Level Stairway was being used as a storage area for the storage of tables, chairs and water bottles. Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not assuring that the exits are readily assessable at all times in accordance with 7.1. This deficient practice affects two of eight smoke zones. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observations and interview on 10/16/12, revealed that the hinged charting stations in the corridors of Patient Halls 1 & 2 did not automatically retract which would impede the exit corridors. Maintenance Staff A verified these observations.

(A)
Based on record review and staff interview, the facility is not conducting fire drills at varying conditions and times on each shift as required. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a 25 certified beds and a census of 18.

Findings include:

Record review and staff interview on 10/16/12, revealed the facility failed to vary the times of the fire drills on both first and second shifts throughout the last 12 months. All fire drills on 1st shift were held between the hours of 0807 and 0909. All fire drills on the 2nd shift were held between the hours of 1915 and 2040. Maintenance Staff A verified these observations.

(B)
Based on record review and staff interview, the facility is not properly documenting and performing the fire drills as required. Fire drill forms were incomplete and silent drills were held on 2nd and 3rd shifts and testing of the alarm the following day of the silent drills were not being performed. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a 25 certified beds and a census of 18.

Findings include:

1. Record review and staff interview on 10/16/12, revealed the facility had incomplete fire drill forms. Most of the sections had lines though them, just indicating the time and date of the drill with no other information available.
2. Record review and staff interview on 10/16/12, revealed the facility was only conducting live fire drills activating the fire alarm system on 1st shift only.
3. Record review and staff interview on 10/16/12, revealed the facility failed to test the fire alarm system the following day after silent drills to verify that the system is in proper working order and to verify that the system sends a signal to the monitoring company.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to properly label and protect the primary power supply for the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, 1999 edition, 1-5.2.5.2 . This deficiency affects all occupants of the building. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observation and interview on 10/16/12, revealed the circuit breaker for the fire alarms primary power located in Electrical Room 137B (Panel LS2, Breaker 21) was not properly labeled or mechanically protected. Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. This deficient practice affects one of eight smoke zones. This facility has 25 licensed beds and at the time of the survey the census was 18.

Findings include:

Observation and interview on 10/16/12 revealed a dust coated sprinkler head in Housekeeping Closet 137A. Maintenance Staff A verified this observation.

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. The deficient practice could affect one of eight smoke zones. This facility has 25 certified beds and at the time of the survey the census was 18.

Findings include:

Observation and interview on 10/16/12, revealed a missing junction box cover on the wall in the Utility Room (next to Room E 113). Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility is not assuring that a proper policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and patients. This facility has a 25 certified beds and at the time of the survey the census was 18.

Findings include:

While performing a record review the outage policy on 10/16/12, it was revealed that the facility did not have an outage policy in place for a sprinkler system outage. Maintenance Staff A verified this observation.

Based on observation, record review and interview, the facility is not assuring that a proper policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and patients. This facility has a 25 certified beds and at the time of the survey the census was 18.

Findings include:

While performing a record review the outage policy on 10/16/12, it was revealed that the facility did not have an outage policy in place for a fire alarm system outage. Maintenance Staff A verified this observation.