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Based on observation and staff interview the facility failed to assure that the ambulance addition maintains a two hour fire resistance wall. This deficient practice may cause fire and smoke to travel to adjacent smoke zones in the building. This will affect 2 out of 5 smoke zones in the building. This facility has a capacity of 16 with a census of 3 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 12/22/10 from 11:30 AM to 2:30 PM it was observed that the 1.5 hour fire rated doors to the ambulance bay did not latch properly in the frame when released.

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

Based on observation and staff interview the facility failed to assure that the smoke barrier wall penetrations have been sealed. This deficient practice may cause fire and smoke to travel to adjacent smoke zones. This will affect 2 out of 5 smoke zones. This facility has a capacity of 16 with a census of 3 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 12/22/10 from 11:30 AM to 2:30 PM it was found that 1.5"conduit for computer wires was open on both ends located above the ceiling tiles in the basement smoke barrier wall.

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

Based on record review and staff interview the facility failed to assure that the battery type emergency lights are tested. This deficient practice may result in total darkness until the generator takes over the load. This will affect 2 out of 5 smoke zones. This facility has a capacity of 16 with a census of 3 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 12/22/10 from 11:30 AM to 2:30 PM it was found that the emergency light 30 second and 90 minute testing has not been documented.

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

Based on observation and staff interview the facility failed to assure that electrical wiring meets NFPA 70 codes. This deficient practice may cause fire and smoke in 1 out of 5 smoke zones. This facility has a capacity of 16 with a census of 3 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 12/22/10 from 11:30 AM to 2:30 PM it was found in the H.I.M. room that an extension cord was piggy backed with a power strip for the computer and monitors.

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

Based on observation and staff interview the facility failed to assure that the ambulance addition maintains a two hour fire resistance wall. This deficient practice may cause fire and smoke to travel to adjacent smoke zones in the building. This will affect 2 out of 5 smoke zones in the building. This facility has a capacity of 16 with a census of 3 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 12/22/10 from 11:30 AM to 2:30 PM it was observed that the 1.5 hour fire rated doors to the ambulance bay did not latch properly in the frame when released.

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

Based on observation and staff interview the facility failed to assure that the smoke barrier wall penetrations have been sealed. This deficient practice may cause fire and smoke to travel to adjacent smoke zones. This will affect 2 out of 5 smoke zones. This facility has a capacity of 16 with a census of 3 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 12/22/10 from 11:30 AM to 2:30 PM it was found that 1.5"conduit for computer wires was open on both ends located above the ceiling tiles in the basement smoke barrier wall.

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

Based on record review and staff interview the facility failed to assure that the battery type emergency lights are tested. This deficient practice may result in total darkness until the generator takes over the load. This will affect 2 out of 5 smoke zones. This facility has a capacity of 16 with a census of 3 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 12/22/10 from 11:30 AM to 2:30 PM it was found that the emergency light 30 second and 90 minute testing has not been documented.

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

Based on observation and staff interview the facility failed to assure that electrical wiring meets NFPA 70 codes. This deficient practice may cause fire and smoke in 1 out of 5 smoke zones. This facility has a capacity of 16 with a census of 3 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 12/22/10 from 11:30 AM to 2:30 PM it was found in the H.I.M. room that an extension cord was piggy backed with a power strip for the computer and monitors.

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