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Based on observations, the facility failed to maintain a Type II (111) construction by allowing penetrations in the ceiling to be present. This affects 1 of 15 smoke zones, affecting approximately 2 staff members due to the fact that this deficiency occurred in a non-resident area (Basement). The facility had a capacity of 56 residents and a census of 25.

Findings include:

Observations on 11-2-10, revealed a penetration (approximately ? inch in size) located in the ceiling of the Housekeeping Storeroom located in the basement. This deficiency was corrected during the inspection.

Maintenance Staff A and B confirmed this finding.

Based on record review, the facility failed to vary the times of their fire drills. This would affect all occupants and staff at the facility. The facility had a capacity of 56 residents and a census of 25 residents.

Findings include:

Record review on 11-1-10, revealed the facility was not varying their fire drills on 2 of 3 nursing shifts. During the 2nd shift, the facility documented 2 fire drills at 1500 hours in March and June. During the months of September and December, the facility documented fire drill at 1508 and 1510 hours. During the 3rd shift, the facility documented 4 fire drills at 0645, 0653, 0650 and 0645 hours in the months of January, April, July and October.

Maintenance Staff A and B confirmed this finding.

Based on observations, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. This affects all smoke compartments and all of the facility patients and staff. The facility had a license of 56 and a census of 25.
Findings include:

Observations on 11-2-10, revealed the presence of a remote annunciator panel (storage battery powered) for the emergency generator, but this annunciator only showed if the generator was operating. The panel failed to indicate other trouble alarms that are associated with the generator.
Maintenance Staff A and B confirmed this finding.

Based on observations, the facility failed to maintain the building electrical wiring system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electric Code, 1999 Edition by not placing covers on open electrical junction boxes. This affects 1 of 15 smoke zones, affecting approximately 2 staff members due to the fact that this deficiency occurred in a non-patient area (Administration Area). The facility had a capacity of 56 residents and a census of 25 residents.
Findings include:
Observations on 11-2-10, revealed an open electrical junction box located above the suspended ceiling near the entrance to the Surgery Area.
Maintenance Staff A and B confirmed this finding.

Based on observations, the facility failed to have Alcohol Based Hand Rub dispensers properly located. This affects 1 of 15 smoke zones, affecting approximately 3 patients and 4 staff members. The facility has a capacity of 56 patients and a census of 25 patients.

Findings include:

Observations on 11-2-10, revealed Alcohol Based Hand Rub dispensers located over an electrical source (light switch) in the E.R. Back Hallway near Exam Room #4.

Maintenance Staff A and B confirmed this finding.

Based on observations, the facility failed to maintain a Type II (111) construction by allowing penetrations in the ceiling to be present. This affects 1 of 15 smoke zones, affecting approximately 2 staff members due to the fact that this deficiency occurred in a non-resident area (Basement). The facility had a capacity of 56 residents and a census of 25.

Findings include:

Observations on 11-2-10, revealed a penetration (approximately ? inch in size) located in the ceiling of the Housekeeping Storeroom located in the basement. This deficiency was corrected during the inspection.

Maintenance Staff A and B confirmed this finding.

Based on record review, the facility failed to vary the times of their fire drills. This would affect all occupants and staff at the facility. The facility had a capacity of 56 residents and a census of 25 residents.

Findings include:

Record review on 11-1-10, revealed the facility was not varying their fire drills on 2 of 3 nursing shifts. During the 2nd shift, the facility documented 2 fire drills at 1500 hours in March and June. During the months of September and December, the facility documented fire drill at 1508 and 1510 hours. During the 3rd shift, the facility documented 4 fire drills at 0645, 0653, 0650 and 0645 hours in the months of January, April, July and October.

Maintenance Staff A and B confirmed this finding.

Based on observations, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. This affects all smoke compartments and all of the facility patients and staff. The facility had a license of 56 and a census of 25.
Findings include:

Observations on 11-2-10, revealed the presence of a remote annunciator panel (storage battery powered) for the emergency generator, but this annunciator only showed if the generator was operating. The panel failed to indicate other trouble alarms that are associated with the generator.
Maintenance Staff A and B confirmed this finding.

Based on observations, the facility failed to maintain the building electrical wiring system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electric Code, 1999 Edition by not placing covers on open electrical junction boxes. This affects 1 of 15 smoke zones, affecting approximately 2 staff members due to the fact that this deficiency occurred in a non-patient area (Administration Area). The facility had a capacity of 56 residents and a census of 25 residents.
Findings include:
Observations on 11-2-10, revealed an open electrical junction box located above the suspended ceiling near the entrance to the Surgery Area.
Maintenance Staff A and B confirmed this finding.