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Based on observation an interview, the facility is not providing doors to the corridor that stay latched tightly within the door frames. This deficient practice would not prevent the spread of smoke, affecting all occupants in one of thirteen smoke zones. This facility has a capacity of 25 with a census of 11.

Findings include:

Observation and interview on 10/01/2012 at 1:50 p.m., revealed the door to Kitchenette Room #302 failed to close and latch tightly within the door frame due to faulty latching hardware. The Facility Director verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that one of six 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. It was determined the facility failed to maintain the 30 minute fire resistive rating of the second floor corridor smoke barrier. This deficient practice could affect 11 residents, staff, and visitors. The facility has a capacity of 25 with a census of 11.

Findings include:

1. Observation and interview on 10/01/2012 at 2:30 p.m., revealed the second floor smoke barrier near Soiled Utility Room #215 contained a two inch conduit with a one fourth inch gap above the lay in tile.. According to the facility layout, this was a required barrier.
2. Observation and interview on 10/02/2012 at 10:40 a.m., revealed the corridor smoke barrier near Room #3213 contained a half inch conduit with an open center above the lay in tile.. According to the facility layout, this was a required barrier. The Facility Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the thirteen smoke compartments in the building. This deficient practice could affect 11 residents, staff and visitors. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 10/01/2012 at 1:26 p.m., revealed the facility failed to maintain the Corridor smoke barrier door to the Pharmacy . The west double door failed to close and positively latch while being tested.

2. Observation and interview on 10/02/2012 at 9:51 a.m., revealed the facility failed to maintain the Corridor smoke barrier doors near Office #309 . The double corridor doors failed to close completely while being tested. The Facility Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of thirteen smoke compartments in the building. This could affect all staff in the Centennial Pavilion. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 10/1/12 at 1:05 p.m., revealed the facility failed to separate the Centennial Pavilion Boiler Room from other compartments. This Boiler Room contained a 3/4 inch conduit with a 1/2 inch gap along the west wall.

2. Observation and interview on 10/1/12 at 3:00 p.m., revealed the facility failed to separate Mechanical Room #2082 from other compartments. This Mechanical Room contained two 3/4 inch conduits with a 1/2 inch gap.

3. Observation and interview on 10/2/12 at 9:45 a.m., revealed the facility failed to separate the Tendrils Storage Room from other compartments. This room contained combustible storage and over 100 square feet. The self closing device failed to close and positively latch the door. The Facility Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain emergency egress lighting in the Shellrock Clinic. This deficient practice affects one of one smoke zones and all occupants of the facility. This facility has a capacity of 25 and a census of 11.

Findings include:

Observation and interview on 10/02/2012 at 1:40 p.m., revealed the facility failed to maintain egress lighting at the Shellrock Clinic. Corridor Battery back-up light #10 failed to illuminate while being tested. The Facility Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide a directional exit sign at the end of the corridor for one of three exits. This deficient practice affects 11 residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 10/01/2012 at 9:49 a.m., revealed the facility failed to provide a directional exit sign in the Third Floor Northeast Corridor. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

2. Observation and interview on 10/01/2012 at 10:15 a.m., revealed the facility failed to maintain a directional exit sign in the corridor near Room #3303. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Facility Director verified these observations 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 11 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 11.

Findings include:


1. Observation and interview on 10/02/2012 at 1:30 p.m., revealed the facility failed to maintain the Fire Alarm System in the waiting area of the Shellrock Clinic. This waiting area contained a smoke detector with in three feet of an Air Diffuser.

2. Observation and interview on 10/02/2012 at 1:35 p.m., revealed the facility failed to maintain the Fire Alarm System in the Restroom of the Shellrock Clinic. This Restroom near the West Nurse Station contained a smoke detector with in three feet of an Air Diffuser. The Facility Director verified these observations 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 11 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 10/01/2012 at 1:01 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near Closet #108. This corridor contained a smoke detector with in three feet of an Air Diffuser.

2. Observation and interview on 10/01/2012 at 1:25 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near the Gift Shop. This corridor contained a smoke detector with in three feet of an Air Diffuser.

3. Observation and interview on 10/01/2012 at 1:44 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near Public Restroom #392. This corridor contained a smoke detector with in three feet of an Air Diffuser.

4. Observation and interview on 10/01/2012 at 1:45 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near Conference Room #386. This corridor contained a smoke detector with in three feet of an Air Diffuser.

5. Observation and interview on 10/01/2012 at 1:53 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #304. This room contained a smoke detector with in three feet of an Air Diffuser.

6. Observation and interview on 10/01/2012 at 1:55 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #307. This resident room contained a smoke detector with in three feet of an Air Diffuser.

7. Observation and interview on 10/01/2012 at 1:58 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #315. This resident room contained a smoke detector with in three feet of an Air Diffuser.

8. Observation and interview on 10/01/2012 at 2:00 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #324. This resident room contained a smoke detector with in three feet of an Air Diffuser.

9. Observation and interview on 10/01/2012 at 2:01 p.m., revealed the facility failed to maintain the Fire Alarm System in Soiled Utility Room #342. This resident room contained a smoke detector with in three feet of an Air Diffuser.

10. Observation and interview on 10/01/2012 at 2:05 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #372. This resident room contained a smoke detector with in three feet of an Air Diffuser.

Observation and interview, revealed the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. Based on observation the facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all the residents and staff. This facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview of the mini blinds in the Cardiac Rehab Office on 10/01/12 at 3:10 p.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant.

2. Observation and interview of the mini blinds in Office #2009 on 10/02/12 at 9:55 a.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, 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 all Staff in this room at risk in the event of a fire. The facility had a capacity of 25 and a census of 11.

Findings Include:

Observation and interview on 10/01/2012 at 1:30 p.m., revealed the facility failed to maintain the electrical system in Closet #375. This room contained exposed electrical wires along the ceiling. The Facility Director verified this observation at the time of the survey process.

Based on observation an interview, the facility is not providing doors to the corridor that stay latched tightly within the door frames. This deficient practice would not prevent the spread of smoke, affecting all occupants in one of thirteen smoke zones. This facility has a capacity of 25 with a census of 11.

Findings include:

Observation and interview on 10/01/2012 at 1:50 p.m., revealed the door to Kitchenette Room #302 failed to close and latch tightly within the door frame due to faulty latching hardware. The Facility Director verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that one of six 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. It was determined the facility failed to maintain the 30 minute fire resistive rating of the second floor corridor smoke barrier. This deficient practice could affect 11 residents, staff, and visitors. The facility has a capacity of 25 with a census of 11.

Findings include:

1. Observation and interview on 10/01/2012 at 2:30 p.m., revealed the second floor smoke barrier near Soiled Utility Room #215 contained a two inch conduit with a one fourth inch gap above the lay in tile.. According to the facility layout, this was a required barrier.
2. Observation and interview on 10/02/2012 at 10:40 a.m., revealed the corridor smoke barrier near Room #3213 contained a half inch conduit with an open center above the lay in tile.. According to the facility layout, this was a required barrier. The Facility Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the thirteen smoke compartments in the building. This deficient practice could affect 11 residents, staff and visitors. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 10/01/2012 at 1:26 p.m., revealed the facility failed to maintain the Corridor smoke barrier door to the Pharmacy . The west double door failed to close and positively latch while being tested.

2. Observation and interview on 10/02/2012 at 9:51 a.m., revealed the facility failed to maintain the Corridor smoke barrier doors near Office #309 . The double corridor doors failed to close completely while being tested. The Facility Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of thirteen smoke compartments in the building. This could affect all staff in the Centennial Pavilion. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 10/1/12 at 1:05 p.m., revealed the facility failed to separate the Centennial Pavilion Boiler Room from other compartments. This Boiler Room contained a 3/4 inch conduit with a 1/2 inch gap along the west wall.

2. Observation and interview on 10/1/12 at 3:00 p.m., revealed the facility failed to separate Mechanical Room #2082 from other compartments. This Mechanical Room contained two 3/4 inch conduits with a 1/2 inch gap.

3. Observation and interview on 10/2/12 at 9:45 a.m., revealed the facility failed to separate the Tendrils Storage Room from other compartments. This room contained combustible storage and over 100 square feet. The self closing device failed to close and positively latch the door. The Facility Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain emergency egress lighting in the Shellrock Clinic. This deficient practice affects one of one smoke zones and all occupants of the facility. This facility has a capacity of 25 and a census of 11.

Findings include:

Observation and interview on 10/02/2012 at 1:40 p.m., revealed the facility failed to maintain egress lighting at the Shellrock Clinic. Corridor Battery back-up light #10 failed to illuminate while being tested. The Facility Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide a directional exit sign at the end of the corridor for one of three exits. This deficient practice affects 11 residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 10/01/2012 at 9:49 a.m., revealed the facility failed to provide a directional exit sign in the Third Floor Northeast Corridor. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit.

2. Observation and interview on 10/01/2012 at 10:15 a.m., revealed the facility failed to maintain a directional exit sign in the corridor near Room #3303. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Facility Director verified these observations 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 11 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 11.

Findings include:


1. Observation and interview on 10/02/2012 at 1:30 p.m., revealed the facility failed to maintain the Fire Alarm System in the waiting area of the Shellrock Clinic. This waiting area contained a smoke detector with in three feet of an Air Diffuser.

2. Observation and interview on 10/02/2012 at 1:35 p.m., revealed the facility failed to maintain the Fire Alarm System in the Restroom of the Shellrock Clinic. This Restroom near the West Nurse Station contained a smoke detector with in three feet of an Air Diffuser. The Facility Director verified these observations 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 11 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview on 10/01/2012 at 1:01 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near Closet #108. This corridor contained a smoke detector with in three feet of an Air Diffuser.

2. Observation and interview on 10/01/2012 at 1:25 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near the Gift Shop. This corridor contained a smoke detector with in three feet of an Air Diffuser.

3. Observation and interview on 10/01/2012 at 1:44 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near Public Restroom #392. This corridor contained a smoke detector with in three feet of an Air Diffuser.

4. Observation and interview on 10/01/2012 at 1:45 p.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near Conference Room #386. This corridor contained a smoke detector with in three feet of an Air Diffuser.

5. Observation and interview on 10/01/2012 at 1:53 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #304. This room contained a smoke detector with in three feet of an Air Diffuser.

6. Observation and interview on 10/01/2012 at 1:55 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #307. This resident room contained a smoke detector with in three feet of an Air Diffuser.

7. Observation and interview on 10/01/2012 at 1:58 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #315. This resident room contained a smoke detector with in three feet of an Air Diffuser.

8. Observation and interview on 10/01/2012 at 2:00 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #324. This resident room contained a smoke detector with in three feet of an Air Diffuser.

9. Observation and interview on 10/01/2012 at 2:01 p.m., revealed the facility failed to maintain the Fire Alarm System in Soiled Utility Room #342. This resident room contained a smoke detector with in three feet of an Air Diffuser.

10. Observation and interview on 10/01/2012 at 2:05 p.m., revealed the facility failed to maintain the Fire Alarm System in Patient Room #372. This resident room contained a smoke detector with in three feet of an Air Diffuser.

Observation and interview, revealed the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. Based on observation the facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all the residents and staff. This facility has a capacity of 25 and a census of 11.

Findings include:

1. Observation and interview of the mini blinds in the Cardiac Rehab Office on 10/01/12 at 3:10 p.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant.

2. Observation and interview of the mini blinds in Office #2009 on 10/02/12 at 9:55 a.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, 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 all Staff in this room at risk in the event of a fire. The facility had a capacity of 25 and a census of 11.

Findings Include:

Observation and interview on 10/01/2012 at 1:30 p.m., revealed the facility failed to maintain the electrical system in Closet #375. This room contained exposed electrical wires along the ceiling. The Facility Director verified this observation at the time of the survey process.