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Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating between the 1992 addition and the 2010 addition. This deficient practice affects all occupants including staff, visitors and residents. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 01/21/2015 at 12:58 p.m., revealed an open pipe, (approximately 2 inches), that was not properly sealed extending through the two hour wall separating the 1992 addition from the 2010 4 patient addition. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility is not ensuring that stairwells between floors are enclosed with construction providing a fire resistance rating of at least one hour in accordance with National Fire Protection Association (NFPA) 101, 2000 edition, Life Safety Code, 8.2.5.6 and 19.3.1.1. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 1/21/15 at 12:27 p.m., revealed a penetration, (approximately 1/4 inch), around a conduit extending through the ceiling of the North Stairwell. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.5.4. The facility is composed of protected combustible construction and protected noncombustible construction equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings include:

Observations and staff interview on 1/21/15, between 12:02 p.m. and 12:18 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 3 inches by 5 inches), around conduit extending through the corridor wall of the Boiler Room,
2. There was a penetration, (approximately 3 inches), around an electrical junction box extending through the ceiling of the 4 Patient Mechanical Room.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to properly label the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 53 and a census of 32 residents.

Findings include:

Observation and staff interview on 1/21/15 at 12:30 p.m., revealed the location of the circuit breaker supplying power to the fire alarm system was not labeled at the main fire alarm control panel.

Based on observations and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 edition, 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 an air supply or return vent can impede the operation of the smoke detector. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observations and staff interview on 12:38 p.m., revealed the following deficiencies:

1. There was a smoke detector installed within three feet of an air supply or return vent in the corridor by the Respiratory Care Office.
2. There was a smoke detector installed within three feet of an air supply or return vent in the corridor by the Pre/Post Op Outpatient Surgery Room.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to install the automatic sprinkler system in accordance with National Fire Protection Association, NFPA 13, Standard for the Installation of Sprinkler Systems. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 1/21/15 at 12:12 p.m., revealed the vault in the basement used for storage is not protected by the automatic sprinkler system. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 1/21/15 at 1:15 p.m., revealed the following deficiencies:

1. There was no available documentation of the last 5 year inspection of the sprinkler system.
2. There were no spare sidewall sprinkler heads in the sprinkler system maintenance box. Sidewall sprinklers were observed installed in the Kitchen freezers.

Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 1/21/15 at 10:30 a.m., revealed the facility failed to include voltage and amperage readings for a monthly test under load conducted on 5/11/14. Facility staff indicated that they had a power outage on that date and were using the outage as a monthly load test.

Based on observation and staff 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. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 1/21/15 at 11:57 a.m., revealed an open gap in Electrical Panel NB5, located in the Boiler Room. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating between the 1992 addition and the 2010 addition. This deficient practice affects all occupants including staff, visitors and residents. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 01/21/2015 at 12:58 p.m., revealed an open pipe, (approximately 2 inches), that was not properly sealed extending through the two hour wall separating the 1992 addition from the 2010 4 patient addition. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility is not ensuring that stairwells between floors are enclosed with construction providing a fire resistance rating of at least one hour in accordance with National Fire Protection Association (NFPA) 101, 2000 edition, Life Safety Code, 8.2.5.6 and 19.3.1.1. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 1/21/15 at 12:27 p.m., revealed a penetration, (approximately 1/4 inch), around a conduit extending through the ceiling of the North Stairwell. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.5.4. The facility is composed of protected combustible construction and protected noncombustible construction equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings include:

Observations and staff interview on 1/21/15, between 12:02 p.m. and 12:18 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 3 inches by 5 inches), around conduit extending through the corridor wall of the Boiler Room,
2. There was a penetration, (approximately 3 inches), around an electrical junction box extending through the ceiling of the 4 Patient Mechanical Room.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to properly label the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 53 and a census of 32 residents.

Findings include:

Observation and staff interview on 1/21/15 at 12:30 p.m., revealed the location of the circuit breaker supplying power to the fire alarm system was not labeled at the main fire alarm control panel.

Based on observations and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 edition, 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 an air supply or return vent can impede the operation of the smoke detector. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observations and staff interview on 12:38 p.m., revealed the following deficiencies:

1. There was a smoke detector installed within three feet of an air supply or return vent in the corridor by the Respiratory Care Office.
2. There was a smoke detector installed within three feet of an air supply or return vent in the corridor by the Pre/Post Op Outpatient Surgery Room.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to install the automatic sprinkler system in accordance with National Fire Protection Association, NFPA 13, Standard for the Installation of Sprinkler Systems. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 1/21/15 at 12:12 p.m., revealed the vault in the basement used for storage is not protected by the automatic sprinkler system. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 1/21/15 at 1:15 p.m., revealed the following deficiencies:

1. There was no available documentation of the last 5 year inspection of the sprinkler system.
2. There were no spare sidewall sprinkler heads in the sprinkler system maintenance box. Sidewall sprinklers were observed installed in the Kitchen freezers.

Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 1/21/15 at 10:30 a.m., revealed the facility failed to include voltage and amperage readings for a monthly test under load conducted on 5/11/14. Facility staff indicated that they had a power outage on that date and were using the outage as a monthly load test.

Based on observation and staff 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. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 1/21/15 at 11:57 a.m., revealed an open gap in Electrical Panel NB5, located in the Boiler Room. Maintenance Staff A verified observations during the survey process.