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Based on observation and staff interview the facility failed to assure that the basement combustible storage room has one hour rated construction. This deficient practice may permit smoke and fire to travel to other areas of the building, affecting 2 out of 5 smoke zones. This facility has a capacity of 13 beds with a census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 between 9:00 A.M. and 3:00 P.M. it was observed that the former air handler room is being used as a combustible storage room that contains medical records and bags of bedding material. and the following conditions were observed in this room:
1) Metal ductwork penetrates the ceiling to the main floor and a corridor wall but has no dampers at either location.
2) The corridor wall above the ceiling tile has concrete block broken out to the combustible storage room.
3) A non-fire rated solid core door is used for this room to the corridor.

Staff "M" was present and acknowledged that these findings exists.

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent the proper evacuation in a timely manner, affecting 5 out of 5 smoke zones. This facility has a capacity of 13 beds with a census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 from 9:00 A.M. until 3:30 P.M. it was observed during record review that the night shift did not conduct a fire drill in the 4th quarter of 2009.

Staff "M"was present and acknowledged that this finding exists.

Based on observation and staff interview the facility failed to assure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants when attempting to exit in the event of a fire or other emergency situation, affecting two of five smoke zones. The facility has a capacity of 13 beds with a census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 between 9:00 AM and 3:30 PM the following was observed:

1) The South exit has part of the exterior concrete removed for a construction renovation project which obstructs the exit pathway.

2) The Northeast exit corridor has medical equipment stored (3 blood pressure monitors recharging, wheeled storage supply, wheeled person lift equipment) .

Staff "M" was present and acknowledged that the findings exists.

Based on observation, record review and staff interview the facility failed to assure that the generator was properly tested each month in accordance with NFPA 99. This deficienct practice potentially reduces the reliability of the generator, affecting 5 out of 5 smoke zones in this building. This facility has a capacity of 13 beds with a census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 between 9:00 A.M. to 3:30 P.M. it was found that the generator is not being tested monthly at 30% of its capacity. The generator is rated at 135 Amps and is being tested between 20-30 Amps monthly.

Staff "M" was present and acknowledged that the finding exists.

Based on observation and staff interview the facility failed to assure that power strips and extension cords are properly used to power electrical equipment in the building and meet NFPA 70 code requirements. This deficiency may cause a fire or equipment failure, affecting 3 out of 5 smoke zones in the building. This facility has a capacity of 13 beds with census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 at 9 A.M. until 2:30 P.M. the following was observed:

1.) Two offices for medical records have 4 extension cords piggy backed with power strips for office equipment;

2.) Physical Therapy room has the ultra sound equipment plugged into a power strip;

3.) Three blood pressure monitors are recharging in the main corridor on a power strip by the Northeast exit door;

4.) Dietary storage room has a freezer on an extension cord;

5.) Main dietary kitchen has a wash sink with electrical outlets within 6 feet that are not GFCI;

6.) The basement combustible storage room has a breaker panel obstructed by bags of bedding material.

Staff "M" was present and acknolwedged that the findings exists.

Based on observation and staff interview the facility failed to assure that the basement combustible storage room has one hour rated construction. This deficient practice may permit smoke and fire to travel to other areas of the building, affecting 2 out of 5 smoke zones. This facility has a capacity of 13 beds with a census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 between 9:00 A.M. and 3:00 P.M. it was observed that the former air handler room is being used as a combustible storage room that contains medical records and bags of bedding material. and the following conditions were observed in this room:
1) Metal ductwork penetrates the ceiling to the main floor and a corridor wall but has no dampers at either location.
2) The corridor wall above the ceiling tile has concrete block broken out to the combustible storage room.
3) A non-fire rated solid core door is used for this room to the corridor.

Staff "M" was present and acknowledged that these findings exists.

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent the proper evacuation in a timely manner, affecting 5 out of 5 smoke zones. This facility has a capacity of 13 beds with a census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 from 9:00 A.M. until 3:30 P.M. it was observed during record review that the night shift did not conduct a fire drill in the 4th quarter of 2009.

Staff "M"was present and acknowledged that this finding exists.

Based on observation and staff interview the facility failed to assure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants when attempting to exit in the event of a fire or other emergency situation, affecting two of five smoke zones. The facility has a capacity of 13 beds with a census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 between 9:00 AM and 3:30 PM the following was observed:

1) The South exit has part of the exterior concrete removed for a construction renovation project which obstructs the exit pathway.

2) The Northeast exit corridor has medical equipment stored (3 blood pressure monitors recharging, wheeled storage supply, wheeled person lift equipment) .

Staff "M" was present and acknowledged that the findings exists.

Based on observation, record review and staff interview the facility failed to assure that the generator was properly tested each month in accordance with NFPA 99. This deficienct practice potentially reduces the reliability of the generator, affecting 5 out of 5 smoke zones in this building. This facility has a capacity of 13 beds with a census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 between 9:00 A.M. to 3:30 P.M. it was found that the generator is not being tested monthly at 30% of its capacity. The generator is rated at 135 Amps and is being tested between 20-30 Amps monthly.

Staff "M" was present and acknowledged that the finding exists.

Based on observation and staff interview the facility failed to assure that power strips and extension cords are properly used to power electrical equipment in the building and meet NFPA 70 code requirements. This deficiency may cause a fire or equipment failure, affecting 3 out of 5 smoke zones in the building. This facility has a capacity of 13 beds with census of 6 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 4/13/10 at 9 A.M. until 2:30 P.M. the following was observed:

1.) Two offices for medical records have 4 extension cords piggy backed with power strips for office equipment;

2.) Physical Therapy room has the ultra sound equipment plugged into a power strip;

3.) Three blood pressure monitors are recharging in the main corridor on a power strip by the Northeast exit door;

4.) Dietary storage room has a freezer on an extension cord;

5.) Main dietary kitchen has a wash sink with electrical outlets within 6 feet that are not GFCI;

6.) The basement combustible storage room has a breaker panel obstructed by bags of bedding material.

Staff "M" was present and acknolwedged that the findings exists.