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Based on record review and staff interview the facility failed to assure that fire drills are properly conducted. This may cause a delay of notification and egress from 4 out of 4 smoke zones. This facility is licensed for 23 beds with a census of 7 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/6/10 from 10 AM to 4:30 PM it is observed that the maintenance man pulls the fire alarm for all of the fire drills. Staff is not included in the procedure of pulling the fire alarm.

Staff "M" was present and aware of the finding.

Based on record review and staff interview the facility failed to assure that the sprinkler system is properly maintained in accordance with NFPA 13. This may cause a delay in the activation of the sprinkler system which may affect 1 out of 4 smoke zones. This facility has a capacity of 23 beds with a census of 7 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/6/10 from 10:00 AM to 4:30 PM it was found that no third quarter test has been performed on the sprinkler system in September 2010.

Staff "M" was present and aware of the finding.

Based on record review and staff interview the facility failed to assure that the generator was properly serviced. This deficient practice may cause a power failure of the secondary power source for the entire facility which will affect all 4 smoke zones. This facility is licensed for 23 beds with a census of 7 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/6/10 from 10 AM to 4:30 PM the generator log shows the cooling system antifreeze was tested by a laboratory. The last two test results show the coolant being brown, cloudy and foams which causes hot spots and poor cooling of the generator.

Staff "M" was present and aware of the finding.

Based on observation and staff interview the facility failed to assure that permanent wiring is used in lieu of extension cords and meet NFPA 70 codes. This may cause a fire or smoke hazard which may affect 2 out of 4 smoke zones in the building. This facility has a capacity of 23 beds with census of 7 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/6/10/10 at 10 A.M. to 4:30 PM the following was found:

1.) Extension cord in use for a fan at the nurses station.
2.) Extension cord in use for a copy machine that is located in the information technology room.
3.) The electrical panel is missing a breaker/blank that is located in the information technology room.

Staff "M" was present and aware of the finding.

Based on record review and staff interview the facility failed to assure that fire drills are properly conducted. This may cause a delay of notification and egress from 4 out of 4 smoke zones. This facility is licensed for 23 beds with a census of 7 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/6/10 from 10 AM to 4:30 PM it is observed that the maintenance man pulls the fire alarm for all of the fire drills. Staff is not included in the procedure of pulling the fire alarm.

Staff "M" was present and aware of the finding.

Based on record review and staff interview the facility failed to assure that the sprinkler system is properly maintained in accordance with NFPA 13. This may cause a delay in the activation of the sprinkler system which may affect 1 out of 4 smoke zones. This facility has a capacity of 23 beds with a census of 7 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/6/10 from 10:00 AM to 4:30 PM it was found that no third quarter test has been performed on the sprinkler system in September 2010.

Staff "M" was present and aware of the finding.

Based on record review and staff interview the facility failed to assure that the generator was properly serviced. This deficient practice may cause a power failure of the secondary power source for the entire facility which will affect all 4 smoke zones. This facility is licensed for 23 beds with a census of 7 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/6/10 from 10 AM to 4:30 PM the generator log shows the cooling system antifreeze was tested by a laboratory. The last two test results show the coolant being brown, cloudy and foams which causes hot spots and poor cooling of the generator.

Staff "M" was present and aware of the finding.

Based on observation and staff interview the facility failed to assure that permanent wiring is used in lieu of extension cords and meet NFPA 70 codes. This may cause a fire or smoke hazard which may affect 2 out of 4 smoke zones in the building. This facility has a capacity of 23 beds with census of 7 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/6/10/10 at 10 A.M. to 4:30 PM the following was found:

1.) Extension cord in use for a fan at the nurses station.
2.) Extension cord in use for a copy machine that is located in the information technology room.
3.) The electrical panel is missing a breaker/blank that is located in the information technology room.

Staff "M" was present and aware of the finding.