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Based on observation, the facility failed to maintain the interior finish. This deficient practice affects the OB wing smoke compartment. The facility has 25 certified beds and at the time of the survey the census was 10.

Findings include:

Observation on 2-17-10 revealed that the west wall in OB clean utility had a 1 inch by 3 inch hole in the sheet rock.

Maintenance Staff A confirmed observations during the survey process.

Based on observation, the facility failed to provide 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 5 smoke zones. This facility has a capacity of 25 with a census of 10 residents.

Findings include:

Observations on 2-17-10, revealed the door to Surgery Consultant Room would not stay closed tightly within the door frame due to the frame did not have a strike plate to hold the door closed.

Maintenance Staff A confirmed these observations.

Based on observation, the facility failed to ensure that hazardous areas were separated from other areas by self-closing doors to ensure a smoke-resistance rating. This deficient practice affects all occupants in one smoke zone in the event of a fire. This facility has a capacity of 25 and a census of 10 residents.
Findings include:
Observations on 2-17-10, revealed the door to the patient Room 116 did not have a closure on the door. The facility, at the time of inspection, was using room 116 as a storage room.
Maintenance Staff A confirmed these observations.

Based on observation, the facility failed to maintain and test fire extinguishers as required. Two of eight fire extinguishers in one of five smoke compartments were affected by the deficient practice. The deficient practice could affect all residents and staff in the facility as this affects the patient wing. The facility has 25 certified beds and at the time of the survey the census was 10.

Findings include:

Observation of the fire extinguishers on 2-17-10, revealed that two of the extinguishers were missing monthly inspections. There were no date or initials marked on the extinguisher tags as required at the following locations: corridor by the Purchasing Directors Office and the corridor by the Dexa- Scanner Room did not have a January inspection.

Maintenance staff A verified observation during the survey process.

Based on observation, the facility failed to provide privacy curtain with the required 1/2 inch mesh. This occurred in 21 rooms throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

Observations on 2-17-10, revealed the following:

1. The Resident Rooms in the Patient Wing had privacy curtains, however, the mesh was smaller than 1/2 inch.

2. The Whirl Pool Room had a privacy curtains, however, the mesh was smaller than 1/2 inch.


Maintenance Staff A verified these observations during the survey process.

Based on observation, the facility failed to provide proper wiring within the facility. The location of deficient practice was located in two of five smoke compartments affecting all of the residents in that compartment. The facility census was 10 with a capacity of 25.

Findings include:

On 2-17-10, the following was observed:
1. The electrical panel NP3 had a void inside the panel for breaker #19.
2. The electrical panel LH in ER corridor was not labeled.

Maintenance Staff A confirmed observations

Based on observation, the facility failed to maintain the interior finish. This deficient practice affects the OB wing smoke compartment. The facility has 25 certified beds and at the time of the survey the census was 10.

Findings include:

Observation on 2-17-10 revealed that the west wall in OB clean utility had a 1 inch by 3 inch hole in the sheet rock.

Maintenance Staff A confirmed observations during the survey process.

Based on observation, the facility failed to provide 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 5 smoke zones. This facility has a capacity of 25 with a census of 10 residents.

Findings include:

Observations on 2-17-10, revealed the door to Surgery Consultant Room would not stay closed tightly within the door frame due to the frame did not have a strike plate to hold the door closed.

Maintenance Staff A confirmed these observations.

Based on observation, the facility failed to ensure that hazardous areas were separated from other areas by self-closing doors to ensure a smoke-resistance rating. This deficient practice affects all occupants in one smoke zone in the event of a fire. This facility has a capacity of 25 and a census of 10 residents.
Findings include:
Observations on 2-17-10, revealed the door to the patient Room 116 did not have a closure on the door. The facility, at the time of inspection, was using room 116 as a storage room.
Maintenance Staff A confirmed these observations.

Based on observation, the facility failed to maintain and test fire extinguishers as required. Two of eight fire extinguishers in one of five smoke compartments were affected by the deficient practice. The deficient practice could affect all residents and staff in the facility as this affects the patient wing. The facility has 25 certified beds and at the time of the survey the census was 10.

Findings include:

Observation of the fire extinguishers on 2-17-10, revealed that two of the extinguishers were missing monthly inspections. There were no date or initials marked on the extinguisher tags as required at the following locations: corridor by the Purchasing Directors Office and the corridor by the Dexa- Scanner Room did not have a January inspection.

Maintenance staff A verified observation during the survey process.

Based on observation, the facility failed to provide privacy curtain with the required 1/2 inch mesh. This occurred in 21 rooms throughout the facility. This facility has a capacity of 25 and a census of 10.

Findings include:

Observations on 2-17-10, revealed the following:

1. The Resident Rooms in the Patient Wing had privacy curtains, however, the mesh was smaller than 1/2 inch.

2. The Whirl Pool Room had a privacy curtains, however, the mesh was smaller than 1/2 inch.


Maintenance Staff A verified these observations during the survey process.

Based on observation, the facility failed to provide proper wiring within the facility. The location of deficient practice was located in two of five smoke compartments affecting all of the residents in that compartment. The facility census was 10 with a capacity of 25.

Findings include:

On 2-17-10, the following was observed:
1. The electrical panel NP3 had a void inside the panel for breaker #19.
2. The electrical panel LH in ER corridor was not labeled.

Maintenance Staff A confirmed observations