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Based on observation and staff interview, it was determined that the facility has failed to provide proper separation for hazardous rooms. This deficient practice fails to ensure the spread of smoke and fire, affecting 1 of 5 smoke compartments. This facility has a capacity of 21 beds with a census of 5 patients at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/27/10 between 9:12 am. and 9:48 am., the following is observed:

1) The first floor nurses' storage room has two open penetrations around pipes in the southwest corner of the room.

2) The first floor west end storage room has an opening in the ceiling.

The Maintenance Director was present and aware of these findings.

Based on record reviews and staff interviews, the facility does not assure that fire drills are conducted at least quarterly on each shift . This deficient practice fails to ensure that staff is prepared for evacuation procedures in the event of an actual emergency, affecting 5 of 5 smoke compartments. This facility has a capacity of 21 beds and a census of 5 patients at the time of survey.

FINDINGS INCLUDE:

During the tour on 1/27/10 at 10:05 a.m., the following is observed during records review:

There is no documentation available proving that a fire drill was conducted for the 7:00 a.m. to 3:00 p.m. shift during the month of February 2009, for the previous 4 quarters reviewed. There was a written statment on the report record indicating that due to patient load, a fire drill was not conducted during that month.

The Maintenance Director was present and is aware of this finding.

Based on observation and record review, the facility failed to provide documentation ensuring that the sprinkler system is being tested quarterly. This deficient practice fails to ensure the effectiveness of the fire suppression system and place occupants are risk of injury in the event of a fire, affecting 5 of 5 smoke compartments. The facility has a capacity of 21 beds with a census of 5 patients at the time of survey.

FINDINGS INCLUDE:

During the tour on 1/27/10 at 9:30 a.m., the following is observed during record review:

The facility could not provide documentation proving that the required quarterly testing is being conducted on the sprinkler system.

The Director of Maintenance was present and aware of this finding.

Based on observation and staff interview, the facility does not assure that electrical equipment is maintained in accordance with NFPA 70. This deficient practice fails to ensure the safe operation of electrial equipment, affecting 1 of 5 smoke compartments. This facility has a capacity of 21 beds with a census of 5 patients at the time of survey.

FINDINGS INCLUDE:

During the tour on 1/27/10 at 11:15 a.m., the following is observed:

The second floor utility closet located next to room #112 was found to have the metal cover of the electrial panel box. The cover was located on the floor.

The Director of Maintenance was present and aware of the finding.

Based on observation and staff interview, it was determined that the facility has failed to provide proper separation for hazardous rooms. This deficient practice fails to ensure the spread of smoke and fire, affecting 1 of 5 smoke compartments. This facility has a capacity of 21 beds with a census of 5 patients at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/27/10 between 9:12 am. and 9:48 am., the following is observed:

1) The first floor nurses' storage room has two open penetrations around pipes in the southwest corner of the room.

2) The first floor west end storage room has an opening in the ceiling.

The Maintenance Director was present and aware of these findings.

Based on record reviews and staff interviews, the facility does not assure that fire drills are conducted at least quarterly on each shift . This deficient practice fails to ensure that staff is prepared for evacuation procedures in the event of an actual emergency, affecting 5 of 5 smoke compartments. This facility has a capacity of 21 beds and a census of 5 patients at the time of survey.

FINDINGS INCLUDE:

During the tour on 1/27/10 at 10:05 a.m., the following is observed during records review:

There is no documentation available proving that a fire drill was conducted for the 7:00 a.m. to 3:00 p.m. shift during the month of February 2009, for the previous 4 quarters reviewed. There was a written statment on the report record indicating that due to patient load, a fire drill was not conducted during that month.

The Maintenance Director was present and is aware of this finding.

Based on observation and record review, the facility failed to provide documentation ensuring that the sprinkler system is being tested quarterly. This deficient practice fails to ensure the effectiveness of the fire suppression system and place occupants are risk of injury in the event of a fire, affecting 5 of 5 smoke compartments. The facility has a capacity of 21 beds with a census of 5 patients at the time of survey.

FINDINGS INCLUDE:

During the tour on 1/27/10 at 9:30 a.m., the following is observed during record review:

The facility could not provide documentation proving that the required quarterly testing is being conducted on the sprinkler system.

The Director of Maintenance was present and aware of this finding.

Based on observation and staff interview, the facility does not assure that electrical equipment is maintained in accordance with NFPA 70. This deficient practice fails to ensure the safe operation of electrial equipment, affecting 1 of 5 smoke compartments. This facility has a capacity of 21 beds with a census of 5 patients at the time of survey.

FINDINGS INCLUDE:

During the tour on 1/27/10 at 11:15 a.m., the following is observed:

The second floor utility closet located next to room #112 was found to have the metal cover of the electrial panel box. The cover was located on the floor.

The Director of Maintenance was present and aware of the finding.