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Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of eight smoke compartments in the building. These areas could affect all occupants in the Basement area. The facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

1) During observation of the Kitchen in the Basement on 08/30/11, revealed that the corridor door to the room was not closing with the self closer that was installed on the door.

2) During observation of the Material Management Storage in the Basement on 08/30/11, revealed that the corridor door to the room was not equipped with the self closing device.

3) During observation of the Maintenance Shop in the Basement on 08/30/11, revealed an 1/2 inch penetration surrounding a plumbing pipe in the ceiling. Maintenance Staff verified these observations during the survey process.

Based on observation and interview the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects eight of eight smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

Observation and interview of the facility's maintenance records on 8/30/11, revealed that there was documentation showing that the testing of the emergency battery lighting system had been done, but did not show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

Observation and interview of the facility ' s fire drill records on 8/30/11, revealed that the 3rd shift drills were missing for three out of fours quarters. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all eight smoke compartments, all occupants of the building, including staff, visitors and patients. This facility has a capacity of 25 with a census of 11.

Findings include:

Observation and interview on 8/30/11, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical panel (#21 EPI) was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice. Maintenance Staff A verified this observation at the time of the survey.

Based on observation and interview, 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 could affect one of eight smoke compartments of the building and all occupants and staff in this smoke compartment. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation on 8/30/11, the Rehab Area had several smoke detectors throughout that were within two feet of air supplies; waiting room, corridor, and exam rooms. Maintenance Staff verified these observations during the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of eight smoke compartments in the building. These areas could affect all occupants in the Basement area. The facility has 25 certified beds and at the time of the survey the census was 11.

Findings include:

1) During observation of the Kitchen in the Basement on 08/30/11, revealed that the corridor door to the room was not closing with the self closer that was installed on the door.

2) During observation of the Material Management Storage in the Basement on 08/30/11, revealed that the corridor door to the room was not equipped with the self closing device.

3) During observation of the Maintenance Shop in the Basement on 08/30/11, revealed an 1/2 inch penetration surrounding a plumbing pipe in the ceiling. Maintenance Staff verified these observations during the survey process.

Based on observation and interview the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects eight of eight smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

Observation and interview of the facility's maintenance records on 8/30/11, revealed that there was documentation showing that the testing of the emergency battery lighting system had been done, but did not show that the monthly tests were conducted for 30 seconds or that an annual test was completed for 90 minutes under load. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

Observation and interview of the facility ' s fire drill records on 8/30/11, revealed that the 3rd shift drills were missing for three out of fours quarters. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all eight smoke compartments, all occupants of the building, including staff, visitors and patients. This facility has a capacity of 25 with a census of 11.

Findings include:

Observation and interview on 8/30/11, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical panel (#21 EPI) was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice. Maintenance Staff A verified this observation at the time of the survey.

Based on observation and interview, 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 could affect one of eight smoke compartments of the building and all occupants and staff in this smoke compartment. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

Observation on 8/30/11, the Rehab Area had several smoke detectors throughout that were within two feet of air supplies; waiting room, corridor, and exam rooms. Maintenance Staff verified these observations during the survey process.