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Based on observation and interview with facility staff, it was determined that the facility failed to ensure 2 of the 4 smoke barrier walls were properly maintained. In the event of a fire 12 of the 25 patients may be affected.

Findings Include:

On 07/13/22010 at 1:15 p.m. observation revealed penetrations in the smoke barrier walls near medical records and the emergency room that were not fire stopped.

At the time of observation on 07/13/2010 staff member M stated he/she was not sure how the penetrations were made.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure doors to all hazardous areas were self closing. In the event of a fire in these areas all 25 patients may be affected.

Findings Include:

On 07/13/2010 between 10:00 a.m. and 3:00 p.m. observation revealed all hazardous area doors were held open by door stops attached to the doors.

During the exit interview at 3:15 p.m. staff member M stated he/she did not know the stops were unacceptable.

Based on record review and interview with facility staff, it was determined that the facility failed to ensure fire drills were conducted once per quarter per shift. All 25 residents may be affected if facility staff was unaware of responsibilities in a fire emergency.

Findings Include:

On 07/13/2010 at 9:50 a.m. record review revealed no fire drill was conducted at the facility during the 1st quarter of 2010.

At the time of record review on 07/13/2010 staff member M stated he/she was away from the facility due to medical reasons during that quarter and he/she was usually responsible for conducting drills.

Based on record review and interview with facility staff, it was determined that the facility failed to ensure proper testing of all components of the sprinkler system. All 25 patients may be affected should the sprinkler system fail in the event of a fire.

Findings Include:

On 07/13/2010 at 9:45 a.m. record review revealed sprinkler supervisory devices were not tested semiannually and water flow alarms were not tested quarterly during the past 12 month period.

On 07/13/2010 at 9:55 a.m. staff member M stated the facility relied on an outside vendor to perform testing and the vendor had not made the facility aware of the testing frequency.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure 2 of the 4 smoke barrier walls were properly maintained. In the event of a fire 12 of the 25 patients may be affected.

Findings Include:

On 07/13/22010 at 1:15 p.m. observation revealed penetrations in the smoke barrier walls near medical records and the emergency room that were not fire stopped.

At the time of observation on 07/13/2010 staff member M stated he/she was not sure how the penetrations were made.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure doors to all hazardous areas were self closing. In the event of a fire in these areas all 25 patients may be affected.

Findings Include:

On 07/13/2010 between 10:00 a.m. and 3:00 p.m. observation revealed all hazardous area doors were held open by door stops attached to the doors.

During the exit interview at 3:15 p.m. staff member M stated he/she did not know the stops were unacceptable.

Based on record review and interview with facility staff, it was determined that the facility failed to ensure fire drills were conducted once per quarter per shift. All 25 residents may be affected if facility staff was unaware of responsibilities in a fire emergency.

Findings Include:

On 07/13/2010 at 9:50 a.m. record review revealed no fire drill was conducted at the facility during the 1st quarter of 2010.

At the time of record review on 07/13/2010 staff member M stated he/she was away from the facility due to medical reasons during that quarter and he/she was usually responsible for conducting drills.

Based on record review and interview with facility staff, it was determined that the facility failed to ensure proper testing of all components of the sprinkler system. All 25 patients may be affected should the sprinkler system fail in the event of a fire.

Findings Include:

On 07/13/2010 at 9:45 a.m. record review revealed sprinkler supervisory devices were not tested semiannually and water flow alarms were not tested quarterly during the past 12 month period.

On 07/13/2010 at 9:55 a.m. staff member M stated the facility relied on an outside vendor to perform testing and the vendor had not made the facility aware of the testing frequency.