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Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one smoke compartment on 1st floor and one smoke compartment in the basement level. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

1. Observation of the Basement Mechanical room on 9/13/16 at 2:45 p.m. revealed a 4 inch penetration surrounding a 4 inch sewer pipe in the ceiling. Maintenance Staff confirmed this observation during the survey process.

2. Observation of the 1st Floor Electrical room on 9/13/16 at 3:02 p.m. revealed a 1/2 inch penetration surrounding a metal conduit in the ceiling located above the electrical panel. Maintenance Staff confirmed this observation during the survey process.

Based upon record review and interview, the facility failed to hold fire drills under varied conditions at different times for the second shift (four out of four quarters) as required by Section A.19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 8.

Findings include:

Observation of record review and interview on 9/13/16 at 1:55 p.m., the facility fire drill documentation showed that the second shift drills were conducted within the same hour for all four quarters. Maintenance Staff verified the documentation during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one smoke compartment on 1st floor and one smoke compartment in the basement level. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

1. Observation of the Basement Mechanical room on 9/13/16 at 2:45 p.m. revealed a 4 inch penetration surrounding a 4 inch sewer pipe in the ceiling. Maintenance Staff confirmed this observation during the survey process.

2. Observation of the 1st Floor Electrical room on 9/13/16 at 3:02 p.m. revealed a 1/2 inch penetration surrounding a metal conduit in the ceiling located above the electrical panel. Maintenance Staff confirmed this observation during the survey process.

Based upon record review and interview, the facility failed to hold fire drills under varied conditions at different times for the second shift (four out of four quarters) as required by Section A.19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 8.

Findings include:

Observation of record review and interview on 9/13/16 at 1:55 p.m., the facility fire drill documentation showed that the second shift drills were conducted within the same hour for all four quarters. Maintenance Staff verified the documentation during the survey process.