HospitalInspections.org

Based on observation and interview, the facility is not ensuring that common wall separated from other areas by partitions and self-closing doors to ensure a two-hour fire-resistance rating. This deficient practice affects all occupants in both buildings due to this would not stop the spread of fire and smoke, in the event of a fire. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

Observation on 9/7/11 at approximately 10:00 a.m., revealed the separation doors located in the Emergency room and the Communication Room did not contain 1 1/2 hour fire rating labels. The separation wall was a 2 hour fire rated wall but the doors were labeled as 20 minute rated.

Maintenance Staff (B) confirmed this observation.

Based on observation and interview, this facility is not assuring that the smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all staff, visitors and residents of the building. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

1. Observation and interview on 9-7-11 at approximately 9:15 a.m.,revealed the 2 hour fire barrier on the 2nd floor next to Room #221 above the lay-in tile ceiling tile, contained a 1/2 inch gap around a 3 inch PVC pipe.

2. Observation and interview on 9-7-11 at approximately 9:30 a.m., revealed the 2 hour fire barrier on the 2nd floor next to Room #234 above the lay-in tile ceiling tile, contained a 1/2 inch gap around a sprinkler pipe. The gap was partially filled with an expandable foam. Maintenance Staff (A) was unable to provide the fire-rating of the product that was used to seal this hole.

3. Observation and interview on 9-7-11 at approximately 10:30 a.m., the 2 hour fire barrier on the 1st Floor East Corridor over the fire doors above the lay-in tile ceiling tile contained two two inch holes in the fire wall.

Maintenance Staff (A) verified this observation.

(A)
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 five smoke compartments in the building. This area could affect residents, visitors and all staff members. The facility has 25 certified beds and at the time of the survey the census was 13.

Findings include:

Observation and staff interview of the 1st floor Pharmacy separation from the egress area on 09/7/11, revealed that overhead vertical rolling door had not had an annual inspection conducted. All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually. A written record shall be maintained and shall be made available to the authority having jurisdiction (National Fire Protection Association 80 Chapter 15 15-2.4.3).

Maintenance Staff (A) confirmed this observation.

(B)
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 six zones in the building. These areas could affect approximately 1 residents and staff members. The facility has 25 certified beds and at the time of the survey the census was 13.

Findings include:

During observation of Break Room #210 in the 2nd Floor Corridor on 9-7-11 at approximately 9:40 a.m., revealed the corridor door to the Break room (which is used for combustible storage) was not provided with a self closing device on the door.

Maintenance Staff (A) verified this observation.

(A)
Based on observation and interview, the facility is not providing a readily visible, durable sign for the delayed corridor exit doors. This deficient practice affects all occupants including staff, visitors and residents, in this facility with a capacity of 25 and a census of 13 residents.

Findings include:

Observation and interview on 09/07/11 at approximately 9:45 a.m., revealed the facility contained an exit door that was equipped with a 15-second delayed egress lock. The O.B. Stairwell exit door was not provided with a readily visible, durable sign in letters no less than 1 inch high and not less then 1/8 inch in stroke width on a contrasting background that reads as follows: "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS". Life Safety Code 2000 edition 7.2.1.6.1 (d), 19.2.1.

Maintenance Staff (A) verified this observation.

(B)
Based on observation and staff interview, this facility is not providing unobstructed corridors that provides a clear path of egress for one of six smoke zones. This facility has a capacity of 25 with a census of 13.

Findings include:

Observation and interview on 9/7/11, the 2nd Floor Corridor next to Room #215 was not maintained to be clear and unobstructed. Testing of the hinged charting station indicated that the station tray did not automatically close.

Maintenance Staff A verified the observation. According to the facility layout, this was a required exit.

Based on observation and interview, the facility did not provide a directional exit signs at the end of the resident corridor for two of six wings. This deficient practice effects numerous residents, staff and visitors in this facility with a capacity of 25. The facility had a census of 13 residents.

Findings include:

Observations and interview on 9-7-11, revealed the exit corridors in the following wings were not equipped with exit signs on the end of the corridors next to the smoke doors. It was observed that when the smoke doors are in the closed position, two exit signs were not visible.

1. Observations on 9-7-11 at approximately 9:30 a.m. the 2nd floor next to Room #234 was missing an exit sign next to the smoke doors affecting approximately 6 residents.

2. Observations on 9-7-11 at approximately 9:15 a.m. the 2nd floor next to Room #221 was missing an exit sign next to the smoke doors affecting approximately 9 residents.

3. Observations on 9-7-11 at approximately 10:18 a.m. the 1st floor East Corridor next to the smoke doors the exit sign was not illuminated at the time of inspection.

Maintenance Staff (A) verified these observations.

Based upon record review and interview, the facility failed to properly document fire drills for one 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 a capacity of 25 with a census of 13.

Findings include:

1. Record review and interview on 9/6/11, revealed the facility was missing documentation for the fire drills conducted during the months of April, May, June for the 2nd Shift.
Maintenance Staff (A) verified the documentation and verified that this drill may not have not been conducted.

2. Record review and interview on 9/6/11, revealed the facility was conducting fire drills on the third shift for all four quarters at approximately the same time during the shift. The drills were conducted as follows: 3-16-11 at 6:35 a.m., 5-26-11 at 6:15 a.m., 7-29-11 at 6:30 a.m., and 12-9-10 at 6:17 a.m.

Maintenance Staff (A) verified the documentation and verified that this drill may not have not been conducted.

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 occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 13.

Findings include:

1. Observation on 09-07-11, revealed the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical panel LS1 breaker #6 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.

2. Observation on 09-06-11, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker at the Ackley Medical Center located in the electrical panel BX3 breaker #53 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.

3. Observation on 09-06-11, the facility failed to provide a properly maintained fire alarm system. The fire alarm remote annunciator next the front entrance at the Ackley Medical Center was not operating correctly. The annunciator did not have a display to indicate the function of the Main Fire Alarm Panel which is located in the basement of the Center.

Maintenance Staff (A) verified this observation.

(A)
Based on record review and interview, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility census is 13 with a capacity of 25.

Findings include:

Observation and interview on 9-6-11, the facility was unable to produce documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacturer. Maintenance Staff A verified that the only testing that had been done was a pass/fail test that did not record the sensitivity of the detectors. Iowa Fire Alarm noted in their inspection report dated 1-5-11 that the last sensitivity testing was conducted on 1-12-06.

(B)
Based on observation and interview, this facility is not assuring that the fire alarm system is installed 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. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

Observations on 9-7-11, the following areas had air diffusers that were located within three feet of the smoke detectors:
1. Smoke detector next to air diffuser in the ceiling of the 2nd Floor in the Waiting Area.
2. Smoke detector next to air diffuser in the ceiling of the 2nd Floor in the Pharmacy Office.
3. Smoke detector next to air diffuser in the ceiling of the North 1 Corridor next to Women's Health.
4. Smoke detector next to air diffuser in the ceiling of the Business Office.
5. Smoke detector next to air diffuser in the ceiling of the 1st Floor in the Elevator Lobby.

Maintenance Staff (A) verified these observations.

(A)
Based on observation and interview the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25. The facility failed to maintain the same type of sprinkler heads within a compartment. This item could effect the operation of the heads by delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 13.

Findings include:

Observation and interview of the facility on 9-7-11 at approximately 11:00 a.m., revealed the facility failed to maintain the sprinkler system sprinkler heads in a compartment to be of one temperature rating, which could severely affect system performance. The facility Ground Floor Entrance of the 1999 Building contained a fusible link head next to the separation door with quick response heads through out the remainder of the corridor.

Maintenance Staff (A) verified the observation.

(B)
Observation and interview revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that fire department connection for the sprinkler system are free of foreign material. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 13.

Findings include:

The facility failed to properly maintain the sprinkler system in accordance with NFPA 25 as evidenced by:

Observation and interview on 9/6/11 at approximately 12:47 p.m., showed sprinkler systems fire department connection located on the east outside wall of the facility was blocked by bushes making the connection difficult to see from the street.

This observation was verified with Maintenance Staff (A).

(A)
Based on observation, interview and record review, the facility failed to maintain and test a complete automatic sprinkler system. All smoke compartment in building could be affected by the deficient practice and potentially affected all residents, visitors and staff. The facility has 25 certified beds and at the time of the survey the census was 13.

Findings include:

During the record review of the facility's fire safety components, it was confirmed by testing dates and interview with the facility maintenance personnel, that the facility sprinkler system was not being inspected for the 5 year flow test as required. The record review and interview was conducted on 09/06/11, revealed that the sprinkler system had not had a 5 year flow test conducted. Sprinkler reports from Iowa Fire sprinkler dating back to 01-05-11 indicated that a 5 year flow test was due. The facility was unable to produce documentation that the test had been conducted.

Maintenance Staff (A) confirmed observations during the survey process.

(B)
Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in one of six smoke zones. The facility had a capacity of 25 and a census of 13 at the time of survey.

Findings include:

1. Observations on 09-07-11 at approximately 9:35 a.m., revealed that in the 2nd Floor Waiting Area the fusible link sprinkler head was coated with dust that covered nearly one-half of the deflector.
2. Observations on 09-07-11 at approximately 11:04 a.m., revealed that on the ground floor in the North Stairwell of the 1999 Building two of two of the fusible link sprinkler heads were coated with brown paint covering nearly one-half of the links. The sprinkler heads failed to be replaced.

Maintenance Staff A verified these observations.

Based on observation and interview the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all the staff using the Medical Records area. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

Observation and interview of the mini blinds in the Medical Records Office on 9/7/11 at approximately 11:23 a.m. showed they were not metal and were not tagged as being flame retardant.

Maintenance Staff (A) verified this observation.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a varying census at the time of the survey.

Findings Include:

Observations on 09/06/11 at approximately 11:12 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter (GFCI) electrical outlet in the east wall of the Basement Break Room of the Family Medical Clinic next to the sink. The electrical outlet failed to trip when tested and tested as an open ground.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility is not ensuring that common wall separated from other areas by partitions and self-closing doors to ensure a two-hour fire-resistance rating. This deficient practice affects all occupants in both buildings due to this would not stop the spread of fire and smoke, in the event of a fire. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

Observation on 9/7/11 at approximately 10:00 a.m., revealed the separation doors located in the Emergency room and the Communication Room did not contain 1 1/2 hour fire rating labels. The separation wall was a 2 hour fire rated wall but the doors were labeled as 20 minute rated.

Maintenance Staff (B) confirmed this observation.

Based on observation and interview, this facility is not assuring that the smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all staff, visitors and residents of the building. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

1. Observation and interview on 9-7-11 at approximately 9:15 a.m.,revealed the 2 hour fire barrier on the 2nd floor next to Room #221 above the lay-in tile ceiling tile, contained a 1/2 inch gap around a 3 inch PVC pipe.

2. Observation and interview on 9-7-11 at approximately 9:30 a.m., revealed the 2 hour fire barrier on the 2nd floor next to Room #234 above the lay-in tile ceiling tile, contained a 1/2 inch gap around a sprinkler pipe. The gap was partially filled with an expandable foam. Maintenance Staff (A) was unable to provide the fire-rating of the product that was used to seal this hole.

3. Observation and interview on 9-7-11 at approximately 10:30 a.m., the 2 hour fire barrier on the 1st Floor East Corridor over the fire doors above the lay-in tile ceiling tile contained two two inch holes in the fire wall.

Maintenance Staff (A) verified this observation.

(A)
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 five smoke compartments in the building. This area could affect residents, visitors and all staff members. The facility has 25 certified beds and at the time of the survey the census was 13.

Findings include:

Observation and staff interview of the 1st floor Pharmacy separation from the egress area on 09/7/11, revealed that overhead vertical rolling door had not had an annual inspection conducted. All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually. A written record shall be maintained and shall be made available to the authority having jurisdiction (National Fire Protection Association 80 Chapter 15 15-2.4.3).

Maintenance Staff (A) confirmed this observation.

(B)
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 six zones in the building. These areas could affect approximately 1 residents and staff members. The facility has 25 certified beds and at the time of the survey the census was 13.

Findings include:

During observation of Break Room #210 in the 2nd Floor Corridor on 9-7-11 at approximately 9:40 a.m., revealed the corridor door to the Break room (which is used for combustible storage) was not provided with a self closing device on the door.

Maintenance Staff (A) verified this observation.

(A)
Based on observation and interview, the facility is not providing a readily visible, durable sign for the delayed corridor exit doors. This deficient practice affects all occupants including staff, visitors and residents, in this facility with a capacity of 25 and a census of 13 residents.

Findings include:

Observation and interview on 09/07/11 at approximately 9:45 a.m., revealed the facility contained an exit door that was equipped with a 15-second delayed egress lock. The O.B. Stairwell exit door was not provided with a readily visible, durable sign in letters no less than 1 inch high and not less then 1/8 inch in stroke width on a contrasting background that reads as follows: "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS". Life Safety Code 2000 edition 7.2.1.6.1 (d), 19.2.1.

Maintenance Staff (A) verified this observation.

(B)
Based on observation and staff interview, this facility is not providing unobstructed corridors that provides a clear path of egress for one of six smoke zones. This facility has a capacity of 25 with a census of 13.

Findings include:

Observation and interview on 9/7/11, the 2nd Floor Corridor next to Room #215 was not maintained to be clear and unobstructed. Testing of the hinged charting station indicated that the station tray did not automatically close.

Maintenance Staff A verified the observation. According to the facility layout, this was a required exit.

Based on observation and interview, the facility did not provide a directional exit signs at the end of the resident corridor for two of six wings. This deficient practice effects numerous residents, staff and visitors in this facility with a capacity of 25. The facility had a census of 13 residents.

Findings include:

Observations and interview on 9-7-11, revealed the exit corridors in the following wings were not equipped with exit signs on the end of the corridors next to the smoke doors. It was observed that when the smoke doors are in the closed position, two exit signs were not visible.

1. Observations on 9-7-11 at approximately 9:30 a.m. the 2nd floor next to Room #234 was missing an exit sign next to the smoke doors affecting approximately 6 residents.

2. Observations on 9-7-11 at approximately 9:15 a.m. the 2nd floor next to Room #221 was missing an exit sign next to the smoke doors affecting approximately 9 residents.

3. Observations on 9-7-11 at approximately 10:18 a.m. the 1st floor East Corridor next to the smoke doors the exit sign was not illuminated at the time of inspection.

Maintenance Staff (A) verified these observations.

Based upon record review and interview, the facility failed to properly document fire drills for one 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 a capacity of 25 with a census of 13.

Findings include:

1. Record review and interview on 9/6/11, revealed the facility was missing documentation for the fire drills conducted during the months of April, May, June for the 2nd Shift.
Maintenance Staff (A) verified the documentation and verified that this drill may not have not been conducted.

2. Record review and interview on 9/6/11, revealed the facility was conducting fire drills on the third shift for all four quarters at approximately the same time during the shift. The drills were conducted as follows: 3-16-11 at 6:35 a.m., 5-26-11 at 6:15 a.m., 7-29-11 at 6:30 a.m., and 12-9-10 at 6:17 a.m.

Maintenance Staff (A) verified the documentation and verified that this drill may not have not been conducted.

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 occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 13.

Findings include:

1. Observation on 09-07-11, revealed the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical panel LS1 breaker #6 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.

2. Observation on 09-06-11, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker at the Ackley Medical Center located in the electrical panel BX3 breaker #53 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.

3. Observation on 09-06-11, the facility failed to provide a properly maintained fire alarm system. The fire alarm remote annunciator next the front entrance at the Ackley Medical Center was not operating correctly. The annunciator did not have a display to indicate the function of the Main Fire Alarm Panel which is located in the basement of the Center.

Maintenance Staff (A) verified this observation.

(A)
Based on record review and interview, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility census is 13 with a capacity of 25.

Findings include:

Observation and interview on 9-6-11, the facility was unable to produce documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacturer. Maintenance Staff A verified that the only testing that had been done was a pass/fail test that did not record the sensitivity of the detectors. Iowa Fire Alarm noted in their inspection report dated 1-5-11 that the last sensitivity testing was conducted on 1-12-06.

(B)
Based on observation and interview, this facility is not assuring that the fire alarm system is installed 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. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

Observations on 9-7-11, the following areas had air diffusers that were located within three feet of the smoke detectors:
1. Smoke detector next to air diffuser in the ceiling of the 2nd Floor in the Waiting Area.
2. Smoke detector next to air diffuser in the ceiling of the 2nd Floor in the Pharmacy Office.
3. Smoke detector next to air diffuser in the ceiling of the North 1 Corridor next to Women's Health.
4. Smoke detector next to air diffuser in the ceiling of the Business Office.
5. Smoke detector next to air diffuser in the ceiling of the 1st Floor in the Elevator Lobby.

Maintenance Staff (A) verified these observations.

(A)
Based on observation and interview the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25. The facility failed to maintain the same type of sprinkler heads within a compartment. This item could effect the operation of the heads by delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 13.

Findings include:

Observation and interview of the facility on 9-7-11 at approximately 11:00 a.m., revealed the facility failed to maintain the sprinkler system sprinkler heads in a compartment to be of one temperature rating, which could severely affect system performance. The facility Ground Floor Entrance of the 1999 Building contained a fusible link head next to the separation door with quick response heads through out the remainder of the corridor.

Maintenance Staff (A) verified the observation.

(B)
Observation and interview revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that fire department connection for the sprinkler system are free of foreign material. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 13.

Findings include:

The facility failed to properly maintain the sprinkler system in accordance with NFPA 25 as evidenced by:

Observation and interview on 9/6/11 at approximately 12:47 p.m., showed sprinkler systems fire department connection located on the east outside wall of the facility was blocked by bushes making the connection difficult to see from the street.

This observation was verified with Maintenance Staff (A).

(A)
Based on observation, interview and record review, the facility failed to maintain and test a complete automatic sprinkler system. All smoke compartment in building could be affected by the deficient practice and potentially affected all residents, visitors and staff. The facility has 25 certified beds and at the time of the survey the census was 13.

Findings include:

During the record review of the facility's fire safety components, it was confirmed by testing dates and interview with the facility maintenance personnel, that the facility sprinkler system was not being inspected for the 5 year flow test as required. The record review and interview was conducted on 09/06/11, revealed that the sprinkler system had not had a 5 year flow test conducted. Sprinkler reports from Iowa Fire sprinkler dating back to 01-05-11 indicated that a 5 year flow test was due. The facility was unable to produce documentation that the test had been conducted.

Maintenance Staff (A) confirmed observations during the survey process.

(B)
Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in one of six smoke zones. The facility had a capacity of 25 and a census of 13 at the time of survey.

Findings include:

1. Observations on 09-07-11 at approximately 9:35 a.m., revealed that in the 2nd Floor Waiting Area the fusible link sprinkler head was coated with dust that covered nearly one-half of the deflector.
2. Observations on 09-07-11 at approximately 11:04 a.m., revealed that on the ground floor in the North Stairwell of the 1999 Building two of two of the fusible link sprinkler heads were coated with brown paint covering nearly one-half of the links. The sprinkler heads failed to be replaced.

Maintenance Staff A verified these observations.

Based on observation and interview the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all the staff using the Medical Records area. This facility has a capacity of 25 and a census of 13 residents.

Findings include:

Observation and interview of the mini blinds in the Medical Records Office on 9/7/11 at approximately 11:23 a.m. showed they were not metal and were not tagged as being flame retardant.

Maintenance Staff (A) verified this observation.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a varying census at the time of the survey.

Findings Include:

Observations on 09/06/11 at approximately 11:12 a.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter (GFCI) electrical outlet in the east wall of the Basement Break Room of the Family Medical Clinic next to the sink. The electrical outlet failed to trip when tested and tested as an open ground.

Maintenance Staff (A) verified this observation.