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Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of nine smoke compartments in the building. This could affect all staff in the Laundry Room. The facility has a capacity of 25 and a census of 4.

Findings include:

Observation and interview on 03/11/2013 at 2:25 p.m., revealed the facility failed to separate the Laundry Room from other compartments. This room contained a 1/4 inch gap around the three inch vent pipe penetrating the ceiling. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and record review, the facility failed to provided a properly tested and maintained fire alarm system. This deficient practice affects 9 of 9 smoke compartments and 4 residents, staff and visitors. The facility has a capacity of 25 and a census of 4.

Findings include:

A review of the inspection records for the fire alarm system on 03/11/2013 at 1:45 p.m., revealed the facility failed to maintain the fire alarm system. The facility failed to have a semi-annual test of the fire alarm system. That the last two completed inspection forms of the fire alarm system were dated 12/31/2012 and 10/16/2010. The Maintenance Director verified this through record review at the time of the survey process.

Based on observation and interview, the 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 than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 4 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 4.

Findings include:

1. Observation and interview on 03/11/2013 at 2:40 p.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near the cafeteria. This corridor contained a smoke detector with in three feet of an air diffuser.

2. Observation and interview on 03/11/2013 at 3:00 p.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near the Emergency Room. This corridor contained a smoke detector with in three feet of an air diffuser near exam room E.

3. Observation and interview on 03/11/2013 at 3:10 p.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near patient room #216. This corridor contained a smoke detector with in three feet of an air diffuser.

4. Observation and interview on 03/11/2013 at 3:15 p.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near restroom #224. This corridor contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified these observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. Standard for the installation of Sprinkler Systems, 1999 edition, placing 4 residents, staff and visitors at risk in the event of a fire. The facility has a capacity of 25 and a census of 4.

Observation and interview on 03/11/2013 at 3:25 p.m., revealed the facility failed to maintain the sprinkler system in the Information Technology Room. Three of three sprinkler heads did not contain an escutcheon ring. The Maintenance Director verified this observation at the time of the survey process.