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Based on observation and staff interview the facility failed to assure that the corridor walls were properly sealed above the ceiling tiles, which fails to prevent the spread smoke and fire to another smoke zone.
This may affect 3 out of 7 smoke zones. This facility has a capacity of 25 with a census of 10 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/12/10 between 2:00 and 2:25 P.M,. it was observed that expandable foam had been used to seal the 1 hour rated smoke compartments above corridor doors to the LTCU entrance and the Maintenance Corridor.

The Facility Maintenance Director was present and aware of the findings.

Based on record review and staff interview, the facility failed to assure that the smoke detectors are properly tested and recorded for sensitivity. This may affect the fire alarm activation by delaying initiation of the system. This may affect 7 of 7 smoke compartments. This facility has a capacity of 25 with a census of 10 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/12/10 at 10:40 A.M. it was observed during records review that all smoke detectors sensitivity tested exactly the same at 2.5 for the past two years.

The Facility Maintenance Director was present and aware of the findings.

Based on observation, record review and staff interview the facility failed to assure that the generator is properly tested and documented monthly on all 3 phases, which may cause failure on one of the phases to provide electrical power. This may affect 7 out of 7 smoke compartments. This facility has a capacity of 25 with a census of 10 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/12/10 at 11:00-11:30 A.M. the following was observed:

1) The 1200 AMP, 3 phase generator , was being tested on one phase only. The generator switch was set on leg #2, documentation shows 250-300 AMPS monthly. No documentation for leg 1 & 3. Therefore, the monthly requirement of 30% of the capacity of the generator load is not met.

2) No policy is in place for a generator malfunction.

The Facility Maintenance Director was present and aware of the findings.

Based on record review and staff interview the facility failed to assure that there is a policy on extension cord and power strips used in the hospital, which may cause electrical failure or fire. This may affect 7 out of 7 smoke compartments. The facility has a capacity of 25 with a census of 10 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/12/10 at 10:50 A.M. it was observed that no policy is in place for extension cords and power strips.

The Facility Maintenance Director was present and aware of the findings.

Based on observation and staff interview the facility failed to assure that the corridor walls were properly sealed above the ceiling tiles, which fails to prevent the spread smoke and fire to another smoke zone.
This may affect 3 out of 7 smoke zones. This facility has a capacity of 25 with a census of 10 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/12/10 between 2:00 and 2:25 P.M,. it was observed that expandable foam had been used to seal the 1 hour rated smoke compartments above corridor doors to the LTCU entrance and the Maintenance Corridor.

The Facility Maintenance Director was present and aware of the findings.

Based on record review and staff interview, the facility failed to assure that the smoke detectors are properly tested and recorded for sensitivity. This may affect the fire alarm activation by delaying initiation of the system. This may affect 7 of 7 smoke compartments. This facility has a capacity of 25 with a census of 10 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/12/10 at 10:40 A.M. it was observed during records review that all smoke detectors sensitivity tested exactly the same at 2.5 for the past two years.

The Facility Maintenance Director was present and aware of the findings.

Based on observation, record review and staff interview the facility failed to assure that the generator is properly tested and documented monthly on all 3 phases, which may cause failure on one of the phases to provide electrical power. This may affect 7 out of 7 smoke compartments. This facility has a capacity of 25 with a census of 10 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/12/10 at 11:00-11:30 A.M. the following was observed:

1) The 1200 AMP, 3 phase generator , was being tested on one phase only. The generator switch was set on leg #2, documentation shows 250-300 AMPS monthly. No documentation for leg 1 & 3. Therefore, the monthly requirement of 30% of the capacity of the generator load is not met.

2) No policy is in place for a generator malfunction.

The Facility Maintenance Director was present and aware of the findings.

Based on record review and staff interview the facility failed to assure that there is a policy on extension cord and power strips used in the hospital, which may cause electrical failure or fire. This may affect 7 out of 7 smoke compartments. The facility has a capacity of 25 with a census of 10 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/12/10 at 10:50 A.M. it was observed that no policy is in place for extension cords and power strips.

The Facility Maintenance Director was present and aware of the findings.