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Based upon record review, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. 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 with a census of 1.

Findings include:

During record review and interview on 12/7/10, the facility fire drill documentation showed that all of the second and third shift drills were conducted within the same hour for all four quarters. Maintenance Staff A verified the documentation.

(A)
Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This would affect two of the seven smoke compartments and one patient located in one of these smoke compartments. This facility has a capacity of 25 and a census of 1 residents.

Findings include:

Observation on 12/7/10, the following areas had smoke detectors located within three of a supply unit: Med Surgery hall and Emergency hall.

(B)
Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, which requires that a smoke detector is placed in the room of the fire alarm control unit if not continually occupied. This facility has a capacity of 25 and a census of 1 residents.

Findings include:

Observation on 12/7/10, the room where the fire alarm control unit is located does not contain a smoke detector. This room is not continually occupied.

Based on interview and record review, the facility failed to maintain and test a complete automatic sprinkler system. Seven out of seven smoke compartments in building could be affected by the deficient practice and potentially affected all visitors, staff, and one patient. The facility has 25 certified beds and at the time of the survey the census was 1.

Findings include:

Record review and interview was conducted on 12/7/10, revealed that the sprinkler system had not had a 5 year internal inspection conducted. The facility was unable to produce documentation that the test had been conducted. During the record review of the facility's fire safety components, it was confirmed by testing dates and interview with the facility maintenance personnel, that the facility sprinkler system was not being inspected for the 5 year internal inspection as required.

Maintenance Staff A confirmed observations during the survey process.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing vistors, staff and patients of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 1 at the time of the survey.

Findings Include:

Observations on 12/7/10 revealed the facility failed to maintain the cable bundle located in the two-hour fire wall between the Clinic and the Hospital. This cable bundle was not located in a metal conduit.

Based upon record review, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. 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 with a census of 1.

Findings include:

During record review and interview on 12/7/10, the facility fire drill documentation showed that all of the second and third shift drills were conducted within the same hour for all four quarters. Maintenance Staff A verified the documentation.

(A)
Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This would affect two of the seven smoke compartments and one patient located in one of these smoke compartments. This facility has a capacity of 25 and a census of 1 residents.

Findings include:

Observation on 12/7/10, the following areas had smoke detectors located within three of a supply unit: Med Surgery hall and Emergency hall.

(B)
Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, which requires that a smoke detector is placed in the room of the fire alarm control unit if not continually occupied. This facility has a capacity of 25 and a census of 1 residents.

Findings include:

Observation on 12/7/10, the room where the fire alarm control unit is located does not contain a smoke detector. This room is not continually occupied.

Based on interview and record review, the facility failed to maintain and test a complete automatic sprinkler system. Seven out of seven smoke compartments in building could be affected by the deficient practice and potentially affected all visitors, staff, and one patient. The facility has 25 certified beds and at the time of the survey the census was 1.

Findings include:

Record review and interview was conducted on 12/7/10, revealed that the sprinkler system had not had a 5 year internal inspection conducted. The facility was unable to produce documentation that the test had been conducted. During the record review of the facility's fire safety components, it was confirmed by testing dates and interview with the facility maintenance personnel, that the facility sprinkler system was not being inspected for the 5 year internal inspection as required.

Maintenance Staff A confirmed observations during the survey process.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing vistors, staff and patients of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 1 at the time of the survey.

Findings Include:

Observations on 12/7/10 revealed the facility failed to maintain the cable bundle located in the two-hour fire wall between the Clinic and the Hospital. This cable bundle was not located in a metal conduit.