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Based upon observation, record review and interview, the facility failed to hold fire drills under varied conditions at different times of the night for four of four quarters reviewed. 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 25 certified beds.

Findings include:

Observation, record review and interview on 7/6/11, the facility fire drill documentation showed that all of the night shift drills were conducted within the same hour for all four quarters. Maintenance Staff A verified the documentation 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 facility is certified for 25 beds.

Findings include:

Observation and interview on 7/6/11, revealed the following areas had smoke detectors within 3 feet of air supplies; Draw room (Lab area), 1st floor visitor's elevator and lower level public restroom. Maintenance Staff A verified these observations during the survey process.

Based upon observation, record review and interview, the facility failed to hold fire drills under varied conditions at different times of the night for four of four quarters reviewed. 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 25 certified beds.

Findings include:

Observation, record review and interview on 7/6/11, the facility fire drill documentation showed that all of the night shift drills were conducted within the same hour for all four quarters. Maintenance Staff A verified the documentation 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 facility is certified for 25 beds.

Findings include:

Observation and interview on 7/6/11, revealed the following areas had smoke detectors within 3 feet of air supplies; Draw room (Lab area), 1st floor visitor's elevator and lower level public restroom. Maintenance Staff A verified these observations during the survey process.