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Based on observations, it was determined the facility was a two-story building and consisted of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with one-hour fire rated materials. This deficient practice affects occupants in 1 of 5 zones. The facility has a capacity of 25 and at the time of the survey had a census of 7.

Findings include:

Observations on 10-22-10 and 1-31-11, revealed there were numerous penetrations ranging from 1/2 inch to 6 inches around numerous items in both Mechanical Rooms.

Based on observations, the facility failed to separate hazardous rooms from other areas. This deficient practice affects occupants in 1 of 20 smoke zones. The facility has a capacity for 25 and at the time of the survey the census was 7 residents.

Findings include:

Observations on 10-22-10 and 1-31-11, revealed the drop down door in the Pharmacy was not connected to the fire alarm.

Based on observations and record review, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required in accordance with NFPA 96 and NFPA 17A. Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. Also an owner's inspection shall be completed monthly. The facility has a capacity of 25 and at the time of the survey process the census was 7 residents.

Findings include:

1. Record review on 10-22-10 and 1-31-11, revealed there was no documentation of the monthly owner's inspection of the wet chemical extinguishing system.

2. Record review on 10-22-10 and 1-31-11, revealed the hood and duct system was not connected to the fire alarm.

Based on observations, 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. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Observations on 10-22-10 and 1-31-11, revealed there was an outlet cover missing in Room 434.