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Based on observation and staff interview, the facility failed to provide a construction type with a complete one-hour fire rated UL rated ceiling tile assembly or a continuous membrane ceiling assembly required by the protected non-combustible construction of the building. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 25 and had a census of 12 patience.
Findings include:

1. Observations and staff interviews on 09/12/11, revealed several missing ceiling tiles located in the corridor of the Laundry Room.

2. Observations and staff interviews on 09/12/11, revealed a hole(approximately 8 inches x 8 inches located in the PACU.

3. Observations and staff interviews on 09/12/11, revealed gaps(approximately 1/4 inch) around copper pipes located by the lockers in the Ambulance Garage.

4. Observations and staff interviews on 09/12/11, revealed missing ceiling tiles located in Team Two Storage Room.

5. Observations and staff interviews on 09/12/11, revealed a hole(approximately 4 inches x 4 inches) located in the Penthouse Storage Room.

6. Observations and staff interviews on 09/12/11, revealed gaps (approximately 1/4 inch) located around the pipes going to the hot water heater located in the Team Two Mop Closet.

Maintenance Staff A verified this observation.

Based on observations and staff interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two of the nine smoke compartments in the building. This affect all residents and staff in those zones. This facility has a capacity of 25 and a census of 12 patients.
Findings include

1. Observations and staff interview on 09/12/11, revealed the smoke doors located by Nurses Station did not close and latch properly when tested during this survey. the door was marked #12.

2. Observations and staff interview on 09/12/11, revealed the child protection/anti theft lock did not disengage when the fire alarm was tested.

Maintenance Staff A verified this observation.

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, 19.3.2.1. The facility is composed of protected combustible construction and unprotected 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. The ceilings must be free of any and all penetrations. The facility has a capacity for 25 and at the time of the survey the census was 12 patients.

Findings include:

1. Observations and staff interview on 09/12/11, revealed several doors that need to be self closing. these areas are greater than 50 square feet and are being used for storage of combustibles and are open to the corridors. The areas included are as follow. Room 127, room 128, the Repertory Room, the Endo Scope Storage Room. the Dietary Storage Room, the House Keeping Closet.

2. Observations and Staff interviews on 09/12/11, revealed the door closer on the Team 2 Storage Room did not close and operate properly when tested during this survey.

3. Observations and staff interview on 09/12/11, revealed the door to room 155 Storage Closet did not close and latch properly when tested during this survey.

Maintenance Staff A verified this observation.

Based on observations and staff interview, the facility is not providing unobstructed corridors that provides a clear path of egress for all exits in the building. This facility has a capacity of 25 with a census of 12.

Findings include:

Observations and staff interviews on 09/12/11, revealed the exit corridor located by the Laundry Room was partialy obstructed and the path of egress was not being maintained. Maintenance Staff A verified this observation.

Based upon record review, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 24 with a census of 12.

Findings include:

Record review on 09/12/11, revealed the required fire drills were not conducted at varied times. Drills conducted on the second shift were conducted between 15:08 and 16:05. Maintenance Staff verified this observation.

Based on observation, the facility failed to provide a properly protect and 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 25 and a census of 12 patients.

Findings include:

Observations on 09/12/11, revealed the circuit breaker was not mechanically protected and was not properly labeled. Also the location of the circuit breaker was not labeled on the fire alarm control panel. Maintenance Staff A verified this observation.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (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 HVAC vent can impede the operation of the smoke detector. This facility has a capacity of 25 and a census of 12 residents.

Findings include:

Observations and staff interview on 09/12/11, revealed the following areas had ceiling fans, air supplies, or air returns that were located either directly over or within three feet of the smoke detectors: Apartment 102 of Team Two and Apartment 101.

Based on observations and staff interview and record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition, 5-6.5.2.2 and table 5-6.5.1.2. Sprinklers shall be located so as to minimize obstructions to spray patterns. The facility has 25 certified beds and at the time of the the census was 12.

Findings include:

1. Observations and staff interview and record review on 09/12/11, revealed a valve on the Main Buildings Sprinkler system located in Cardiac Rehab. had a small leak and was exhibiting signs of corrosion.

2. Observations and staff interviews on 09/12/11, revealed loose escussion plates located in the Sterilization Room and in the Hallway by the Respiratory Room and the Number 3 Surgery Room Door.

3. Observations and staff interviews on 09/12/11, revealed a missing escussion ring on the sprinkler head located in the Team 1 and Team 2 Mop Closets. Maintenance Staff A verified this observation.

Based on observations and staff interviews, the facility failed to provide window coverings that were flame resistant in accordance with provisions of National Fire Protection Association (NFPA) 101, 10.3. The facility has a capacity of 25 and at the time the census was 12.


Findings include:

Observations and staff interviews on 09/12/11, revealed window shades located on the Cardiac Rehab Managers Office were made of plastic. Maintenance Staff A verified this observation.

Based on observations, the facility failed to provide doors to storage areas with means of unlatching the door from the egress side. All doors in the facility shall be able to be opened from the inside without the use of a key, tool, or special knowledge. The facility has a capacity of 25 and at the time the census was 12.

Findings include:

Observations on 09/12/11 , revealed a dead bolt on the door located in Home Care and on the doors located in the Kitchen. Maintenance Staff verified this observation.

Based on observations and staff interviews, 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. These deficiencies affect the entire facility and staff. This facility has a capacity of 25 and a census of 12 patience.

Findings include:

1. Observations and staff interviews on 09/12/11, revealed missing switch plate covers in the Administration Area. This area was under construction at the time of this survey .

2. Observation and staff interviews on 09/12/11, revealed an outlet located by a sink, this outlet was not a ground fault circuit interrupter (GFCI). This sink was located in the Home Care Office area.

3. Observation and staff interviews on 09/12/11, revealed a refrigerator plugged into a surge protector located in Waiting Room 140.

4. Observation and staff interviews on 09/12/11, revealed an outlet located by the sink in the Team One Kitchenette was not a required ground fault circuit interrupter(GFCI).

5. Observation and staff interviews on 09/12/11, revealed outlets located by the sinks in all rooms in the Team 2 that were not Ground Fault Circuit Interrupter outlets. these rooms are numbered 120 to 128.

6. Observation and staff interviews on 09/12/11, revealed an outlet located in the following areas that were not Ground Fault Circuit Interrupter outlets. the sink in the Basement Kitchenette, in the Emergency Room By the sink. and in the Physical Therapy Kitchenette.

7. Observation and staff interviews on 09/12/11, revealed an extension cord plugged into a refrigerator located in the Out Patient Room.

Maintenance Staff A verified this observation.

Based on observation and staff interview, the facility failed to provide a construction type with a complete one-hour fire rated UL rated ceiling tile assembly or a continuous membrane ceiling assembly required by the protected non-combustible construction of the building. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 25 and had a census of 12 patience.
Findings include:

1. Observations and staff interviews on 09/12/11, revealed several missing ceiling tiles located in the corridor of the Laundry Room.

2. Observations and staff interviews on 09/12/11, revealed a hole(approximately 8 inches x 8 inches located in the PACU.

3. Observations and staff interviews on 09/12/11, revealed gaps(approximately 1/4 inch) around copper pipes located by the lockers in the Ambulance Garage.

4. Observations and staff interviews on 09/12/11, revealed missing ceiling tiles located in Team Two Storage Room.

5. Observations and staff interviews on 09/12/11, revealed a hole(approximately 4 inches x 4 inches) located in the Penthouse Storage Room.

6. Observations and staff interviews on 09/12/11, revealed gaps (approximately 1/4 inch) located around the pipes going to the hot water heater located in the Team Two Mop Closet.

Maintenance Staff A verified this observation.

Based on observations and staff interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two of the nine smoke compartments in the building. This affect all residents and staff in those zones. This facility has a capacity of 25 and a census of 12 patients.
Findings include

1. Observations and staff interview on 09/12/11, revealed the smoke doors located by Nurses Station did not close and latch properly when tested during this survey. the door was marked #12.

2. Observations and staff interview on 09/12/11, revealed the child protection/anti theft lock did not disengage when the fire alarm was tested.

Maintenance Staff A verified this observation.

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, 19.3.2.1. The facility is composed of protected combustible construction and unprotected 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. The ceilings must be free of any and all penetrations. The facility has a capacity for 25 and at the time of the survey the census was 12 patients.

Findings include:

1. Observations and staff interview on 09/12/11, revealed several doors that need to be self closing. these areas are greater than 50 square feet and are being used for storage of combustibles and are open to the corridors. The areas included are as follow. Room 127, room 128, the Repertory Room, the Endo Scope Storage Room. the Dietary Storage Room, the House Keeping Closet.

2. Observations and Staff interviews on 09/12/11, revealed the door closer on the Team 2 Storage Room did not close and operate properly when tested during this survey.

3. Observations and staff interview on 09/12/11, revealed the door to room 155 Storage Closet did not close and latch properly when tested during this survey.

Maintenance Staff A verified this observation.

Based on observations and staff interview, the facility is not providing unobstructed corridors that provides a clear path of egress for all exits in the building. This facility has a capacity of 25 with a census of 12.

Findings include:

Observations and staff interviews on 09/12/11, revealed the exit corridor located by the Laundry Room was partialy obstructed and the path of egress was not being maintained. Maintenance Staff A verified this observation.

Based upon record review, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 24 with a census of 12.

Findings include:

Record review on 09/12/11, revealed the required fire drills were not conducted at varied times. Drills conducted on the second shift were conducted between 15:08 and 16:05. Maintenance Staff verified this observation.

Based on observation, the facility failed to provide a properly protect and 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 25 and a census of 12 patients.

Findings include:

Observations on 09/12/11, revealed the circuit breaker was not mechanically protected and was not properly labeled. Also the location of the circuit breaker was not labeled on the fire alarm control panel. Maintenance Staff A verified this observation.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (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 HVAC vent can impede the operation of the smoke detector. This facility has a capacity of 25 and a census of 12 residents.

Findings include:

Observations and staff interview on 09/12/11, revealed the following areas had ceiling fans, air supplies, or air returns that were located either directly over or within three feet of the smoke detectors: Apartment 102 of Team Two and Apartment 101.

Based on observations and staff interview and record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition, 5-6.5.2.2 and table 5-6.5.1.2. Sprinklers shall be located so as to minimize obstructions to spray patterns. The facility has 25 certified beds and at the time of the the census was 12.

Findings include:

1. Observations and staff interview and record review on 09/12/11, revealed a valve on the Main Buildings Sprinkler system located in Cardiac Rehab. had a small leak and was exhibiting signs of corrosion.

2. Observations and staff interviews on 09/12/11, revealed loose escussion plates located in the Sterilization Room and in the Hallway by the Respiratory Room and the Number 3 Surgery Room Door.

3. Observations and staff interviews on 09/12/11, revealed a missing escussion ring on the sprinkler head located in the Team 1 and Team 2 Mop Closets. Maintenance Staff A verified this observation.

Based on observations and staff interviews, the facility failed to provide window coverings that were flame resistant in accordance with provisions of National Fire Protection Association (NFPA) 101, 10.3. The facility has a capacity of 25 and at the time the census was 12.


Findings include:

Observations and staff interviews on 09/12/11, revealed window shades located on the Cardiac Rehab Managers Office were made of plastic. Maintenance Staff A verified this observation.

Based on observations, the facility failed to provide doors to storage areas with means of unlatching the door from the egress side. All doors in the facility shall be able to be opened from the inside without the use of a key, tool, or special knowledge. The facility has a capacity of 25 and at the time the census was 12.

Findings include:

Observations on 09/12/11 , revealed a dead bolt on the door located in Home Care and on the doors located in the Kitchen. Maintenance Staff verified this observation.

Based on observations and staff interviews, 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. These deficiencies affect the entire facility and staff. This facility has a capacity of 25 and a census of 12 patience.

Findings include:

1. Observations and staff interviews on 09/12/11, revealed missing switch plate covers in the Administration Area. This area was under construction at the time of this survey .

2. Observation and staff interviews on 09/12/11, revealed an outlet located by a sink, this outlet was not a ground fault circuit interrupter (GFCI). This sink was located in the Home Care Office area.

3. Observation and staff interviews on 09/12/11, revealed a refrigerator plugged into a surge protector located in Waiting Room 140.

4. Observation and staff interviews on 09/12/11, revealed an outlet located by the sink in the Team One Kitchenette was not a required ground fault circuit interrupter(GFCI).

5. Observation and staff interviews on 09/12/11, revealed outlets located by the sinks in all rooms in the Team 2 that were not Ground Fault Circuit Interrupter outlets. these rooms are numbered 120 to 128.

6. Observation and staff interviews on 09/12/11, revealed an outlet located in the following areas that were not Ground Fault Circuit Interrupter outlets. the sink in the Basement Kitchenette, in the Emergency Room By the sink. and in the Physical Therapy Kitchenette.

7. Observation and staff interviews on 09/12/11, revealed an extension cord plugged into a refrigerator located in the Out Patient Room.

Maintenance Staff A verified this observation.