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Based on observation and interview, the facility failed to maintain the fire doors to close and resist the passage of smoke. This facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

Observations and interview on 8/19/15, revealed the double fire doors located at the Nurse's West Hall did not latch properly when tested. Maintenance Staff A verified this observation.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift as required. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 residents and a census of 11.

Findings include:

Record review and staff interview on 8/19/15, revealed the facility failed to perform a fire drill in the 1st quarter on third shift, 3rd quarter on second shift and 4th quarter on first shift. Maintenance Staff A verified these observations.

Based on observations, record review and interview, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. This deficient practice affects occupants in the Kitchen. This facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

Observations, record review and interview on 8/19/15, revealed the two left burners did not automatically ignite on the commercial stove in the Kitchen. A lighter was needed to ignite them. Maintenance Staff A verified this observation.