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Based on observation and interview the facility failed to maintain the required separation of hazardous areas as required by NFPA 101, 2000ed. 19.3.2.1. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 25 and the census was 11.
Findings are:

Observations on 11-8-10 at 10:53 a.m. revealed the door to the storage room next to room 218 did not positive latch. The findings were confirmed by Maintenance A at the time of the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based upon record review and interview, the facility failed to hold fire drills under varied conditions at different times of the day and at least quarterly on each shift for two of four quarters reviewed. This deficient practice affected all residents, visitors, and staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility capacity is 25 and the census was 11.
Findings are:

Observations during record review on 11-8-10 at 12:31 p.m. revealed that no documentation of fire drills for the third shift during the first quarter and for the first and third shifts during the second quarter. The findings were confirmed by Maintenance A at the time of the findings.

NFPA Standard: 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. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. This deficient practice would affect all smoke compartments of the building and all of the residents, visitors and staff. The facility capacity is 25 and the census was 11.
Findings are:

Observations during record review on 11-8-10 at 12:25 p.m. revealed that proper documentation of the generator weekly inspections and run times had not been maintained. Documentation consisted of a log sheet that did show monthly 30-minute load tests but no weekly inspection documentation could be provided. The findings were confirmed by Maintenance A at the time of the findings.


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

Based on staff interview and observation, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70, The National Electrical Code. This practice affected all patients, visitors and staff that use the area of the mammography exam room. The facility capacity is 25 and the census was 11.
Findings are:

Observations on 11-8-10 at 11:23 a.m. revealed a power strip being used to supply electricity to a computer that was not rated as health-care for patient care areas in the mammography exam room. The findings were confirmed by Maintenance A at the time of the findings.

Based on observation and interview the facility failed to maintain the required separation of hazardous areas as required by NFPA 101, 2000ed. 19.3.2.1. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 25 and the census was 11.
Findings are:

Observations on 11-8-10 at 10:53 a.m. revealed the door to the storage room next to room 218 did not positive latch. The findings were confirmed by Maintenance A at the time of the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based upon record review and interview, the facility failed to hold fire drills under varied conditions at different times of the day and at least quarterly on each shift for two of four quarters reviewed. This deficient practice affected all residents, visitors, and staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility capacity is 25 and the census was 11.
Findings are:

Observations during record review on 11-8-10 at 12:31 p.m. revealed that no documentation of fire drills for the third shift during the first quarter and for the first and third shifts during the second quarter. The findings were confirmed by Maintenance A at the time of the findings.

NFPA Standard: 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. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. This deficient practice would affect all smoke compartments of the building and all of the residents, visitors and staff. The facility capacity is 25 and the census was 11.
Findings are:

Observations during record review on 11-8-10 at 12:25 p.m. revealed that proper documentation of the generator weekly inspections and run times had not been maintained. Documentation consisted of a log sheet that did show monthly 30-minute load tests but no weekly inspection documentation could be provided. The findings were confirmed by Maintenance A at the time of the findings.


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

Based on staff interview and observation, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70, The National Electrical Code. This practice affected all patients, visitors and staff that use the area of the mammography exam room. The facility capacity is 25 and the census was 11.
Findings are:

Observations on 11-8-10 at 11:23 a.m. revealed a power strip being used to supply electricity to a computer that was not rated as health-care for patient care areas in the mammography exam room. The findings were confirmed by Maintenance A at the time of the findings.