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Based on observations and interview, the facility failed to maintain 4 of approximately 100 doors within 4 of 6 smoke zones in proper working condition. This deficient practice would affect approximately 8 residents within the affected zones. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The 200 Hall Resident Room 205 revealed the corridor door was propped open with a towel.

2. The Medical Records Corridor Door revealed the door was warped and a space of approximately 1/2 inch was revealed between the door and the door frame when the door was in the closed position.

3. The CT Room revealed 2 of 2 doors that were detached from the door closers that were provided for the doors.

4. The 100 Hall Resident Room 106 revealed the corridor door was warped and revealed a space of approximately 1 inch located at the top of the door between the door and the door frame when the door was in the closed position.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain proper vertical fire separation in 3 of approximately 20 rooms within 2 of 6 smoke zones. This deficient practice could affect approximately 5 residents and approximately 10 staff members within the affected zones. The facility had a capacity of 26 residents and a census of 10 residents.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The North Nurse's Station revealed a vertical cable penetration (approximately 1 inch in size) located by the Security Monitor.

2. The North IV Room revealed a vertical duct penetration (approximately 1/2 inch in size) located in the ceiling lid.

3. The Basement Server Room revealed a vertical wire and cable bundle penetration (approximately 6 inches by 6 inches in size) located by the North wall.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide illuminated exit signs in 1 of 6 smoke zones to properly indicate the direction of travel to exit. This deficient practice would affect approximately 6 staff members. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the Basement Accounts Payable area was not provided with any exit signs to provide the proper direction to travel to an exit. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 of 6 smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects approximately 3 residents and 5 staff members within the affected zone. This facility has a capacity of 25 and a census of 10 residents.

Findings include:

Observation and interview on 1/3/12, revealed a pipe penetration (approximately 1/2 inch in size) located in the 400 Hall Smoke Barrier. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 of 6 sets of smoke barrier doors in proper working condition. This deficient practice would affect approximately 4 residents within the facility. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Observation and interview on 1/3/12, revealed the Fire Barrier Doors to the 300 Hall failed to close and latch properly into the door frame with the swing of the door closers when tested. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of 10 of approximately 15 hazardous areas, in 4 of 6 smoke zones, from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect approximately 10 residents within the affected zones. The facility had a capacity of 25 residents and a census of 10 residents.


Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The Surgery Central Supply Room revealed the door to the Operating Room 1 failed to close and latch properly into the door frame with the swing of the door closer when tested.

2. The Kitchen Pantry revealed the door was not provided with a door closer. This room was a storage room that was greater than 50 square feet in size.

3. The Laboratory revealed a wire penetration (approximately 1/2 inch in size) located in the South Wall.

4. The 300 Hall Storage Room 309 revealed the corridor door was not provided with a door closer device.

5. The 400 Hall Storage Room 4 revealed the corridor door failed to close and latch properly into the door frame with the swing of the door closer when tested.

6. The Boiler Room revealed 2 conduit penetrations (approximately 1/2 inch in size each) located in the East Wall above the door and a conduit penetration (approximately 1 inch in size) located above the East Wall Electrical Panels.

7. The Maintenance Office/Room revealed a conduit penetration (approximately 1/2 inch in size) located above the corridor door.

8. The Basement Elevator Equipment Room revealed rubber garden hose penetrations (approximately 1 inch in size each) in 2 walls within the room. This room also revealed a vertical conduit penetration (approximately 1/2 inch in size) located above the Master Electrical Switch.

9. The Basement "Old Crawl Space" revealed the corridor door was not provided with a door closer. This area is not sprinkled and contained multiple mechanical devices.

10. The Basement "Old Crawl Space" revealed multiple conduit and pipe penetrations (approximately 1 inch up to 4 feet in size) located in the corridor wall to the Accounts Payable Area and the Purchasing Storage Area.

11. The Purchasing Storage Area revealed the door from the Corridor and Accounts Payable Area had been removed.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 12 of approximately 100 rooms in 4 of 6 smoke zones with readily and easily accessible routes and means of egress. This deficient practice would affect approximately 10 residents within the affected zones. The facility had a capacity of 25 residents and census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The 200 Hall revealed tables, chairs, a bench, a tree, and a shelf located in the corridor that obstructed the width of the corridor.

2. The 200 Hall Activities Room revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

3. The Surgery Hallway Recovery Room revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

4. The Surgery Hall Operating Room 1 revealed revealed thumb-bolt latching devices on 2 of 2 doors that would require a tight grip, pinch, and twist to disengage the locks before opening the doors.

5. The Surgery Hall Operating Room 2 revealed a thumb-bolt latching device on the corridor door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

6. The Department of Education Director Office revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

7. The Laundry Room Corridor Door revealed the door hardware was installed at a height of over 5 feet off the ground.

8. The Kitchen Doors revealed thumb-bolt latching devices on the 3 of 3 entry doors that would require a tight grip, pinch, and twist to disengage the locks before opening the doors.

9. The Kitchen Pantry Door revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

10. The 400 Hall Waiting Area File Storage Room Door revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

11. The 400 Hall Mammogram Room revealed a Cage Storage Area that was equipped with a dead bolt lock that required a tight grip, pinch, and twist to disengage the lock mechanism.

12. The Basement Purchasing Storage Area revealed a gated fence with a door equipped with a dead bolt lock that required a tight grip, pinch, and twist to disengage the lock mechanism.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations, record review and interview, the facility failed to properly provide and maintain the emergency lighting units within the facility. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 1/3/12, revealed the following:

1. Record review and interview revealed the facility failed to provide the monthly 30 second testing and the annual 90 minute testing for the emergency lighting units throughout the facility. Interview with the Maintenance Staff A revealed the facility was unaware of this requirement.

2. The Surgery Hall Operating Room 1 revealed the room was not provided with an emergency lighting unit that was separate from the emergency generator to provide uninterrupted lighting in the event of a power failure.

3. The Surgery Hall Operating Room 2 revealed the room was not provided with an emergency lighting unit that was separate from the emergency generator to provide uninterrupted lighting in the event of a power failure.

4. The 400 Hall Direct Exit Door and Pathway revealed the path of egress was not provided with emergency lighting units to properly illuminate the path of egress to a public way in the event of a power failure.

5. The 100 Hall Direct Exit Door and Pathway revealed the path of egress was not provided with emergency lighting units to properly illuminate the path of egress to a public way in the event of a power failure.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 of 2 exit signs in 1 of 6 smoke zones in proper working condition. This deficient practice would affect approximately 2 residents within the affected zone. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Observation and interview on 1/3/12, revealed the exit sign located in the Pharmacy Hall to the CT Exit Door failed to be illuminated. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on record review and interview, the facility failed to provide 3 of 8 fire drills at varying times in 3 of 4 quarters on 1 of 2 staff shifts. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Record review and interview on 1/3/12, revealed the facility provided 3 of 4 fire drills on the Second Staff Shift (7 pm to 7 am) within the 5 a.m. hour. The 1st Quarter Fire Drill for the 2nd Shift was conducted at 0545, the 2nd Quarter Fire Drill for the 2nd Shift was conducted at 0520, and the 4th Quarter Fire Drill for the 2nd Shift was conducted at 0521. The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to maintain the building's fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition. This deficient practice would affect all residents throughout the building. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Record review and interview on 1/3/12, revealed the Fire Alarm Inspection Report did not provide a list of the locations or serial numbers of the initiating and supervisory devices that were tested. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's sprinkler system in 3 of 6 smoke zones accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect approximately 5 residents within the affected zones. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The Pharmacy Hall Isolation Cart Room revealed an excessive amount of dust and dirt on the sprinkler head (1 of 1 sprinkler head).

2. The Kitchen revealed an excessive amount of dust and dirt on 7 of 18 sprinkler heads within the Kitchen.

3. The Basement Maintenance Office/Room revealed the Spare Sprinkler Head Box was not equipped with a sprinkler head wrench.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 6 fire extinguishers in 5 of 6 smoke zones in accordance with the National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 1998 edition. This deficient practice would affect approximately 8 residents within the affected zone. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The Basement Server Room revealed the fire extinguisher was not mounted and was sitting on the ground behind the Corridor door.

2. The Maintenance Room revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

3. The 300 Hall Medical Records Room revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

4. The 300 Hall by the Fire Doors revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

5. The Financial Counselor's Office revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

6. The Front Main Entry Lobby revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

The Facility Maintenance Staff A confirmed this finding on the date of inspection

Based on observation and interview, the facility failed to provide proper venting and ductwork for 1 of 2 laundry areas in 1 of 6 smoke zones. This deficient practice would affect approximately 3 staff members. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observation and interview on 1/3/12, revealed the facility failed to provide proper venting for a clothes dryer unit located in the 300 Hall Laundry Area. At the time of inspection, the dryer in this area revealed the duct work terminated within the room and the top of the duct was covered with a hair-net used as a filter.

Based on observation and interview, the facility failed to provide proper signage for the storage of oxygen in 1 room in 1 of 6 smoke zones. This deficient practice would affect approximately 3 staff members and 3 residents within the affected zone. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Observation and interview on 1/3/12, revealed the 100 Hall Oxygen Storage Room failed to be provided with a sign indicating there was to be No-Smoking within the room. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on record review and interview, the facility failed to provide proper testing and documentation of the building's emergency generator in accordance with the National Fire Protection Association (NFPA) Standard 110, 1999 edition. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Record review and interview on 1/3/12, revealed the testing documentation of the Generator did not provide all required information required by the NFPA Standard 110, 1999 edition. At the time of inspection, the facility's Generator Testing Documentation only indicated the date, time, on/off, comments, and initials of the person completing the documentation. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's electrical system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect approximately 10 residents within the affected zones. The facility had a capacity of 25 residents and had a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The 200 Hall Respiratory Office revealed a refrigerator plugged into a surge protector.

2. The 200 Hall Resident Room 201 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

3. The 200 Hall Resident Room 202 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

4. The 200 Hall Resident Room 203 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

5. The 200 Hall Resident Room 204 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

6. The 200 Hall Resident Room 205 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

7. The 200 Hall Resident Room 206 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

8. The 200 Hall Resident Room 207 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

9. The 200 Hall Resident Room 208 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

10. The 200 Hall Linen Storage Area revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

11. The Surgery Hall revealed exposed electrical wires in a ceiling lighting unit located by the Smoke Barrier Doors.

12. The Surgery Hall Operating Room 1 revealed exposed electrical wires located behind the Clock on the wall..

13. The Pharmacy Hall CT Direct Exit revealed an open electrical junction box located on the exterior of the building.

14. The 100 Hall Resident Room 101 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

15. The 100 Hall Resident Room 102 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

16. The 100 Hall Resident Room 103 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

17. The 100 Hall Resident Room 104 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

18. The 100 Hall Resident Room 105 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

19. The 100 Hall Resident Room 106 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

20. The 100 Hall Resident Room 107 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

21. The 100 Hall Resident Room 108 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

22. The 100 Hall Resident Room 109 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

23. The 100 Hall Resident Room 110 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

24. The 100 Hall Resident Room 111 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

25. The 100 Hall Resident Room 112 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

26. The 100 Hall Cart Storage Area revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

27. The 100 Hall Linen Storage Area revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

28. The 100 Hall IT Room revealed breakers in the Left Electrical Panel B were not properly labeled.

29. The Laundry Room Clean Linen Area revealed storage items within 3 feet of the electrical panel.

30. The Laundry Room revealed an open electrical junction box located behind the Air Handler Unit on the South Wall.

31. The 300 Hall Laundry Area revealed a refrigerator plugged into a plastic surge protector.

32. The 300 Hall Direct Exit by the Oxygen Storage Area revealed an electrical drop cord plugged into a bug zapper.

33. The Maintenance Room revealed a conduit not properly secured to a junction box that revealed exposed electrical wires located on the East wall by the door.

34. The Basement Elevator Equipment Room revealed exposed electrical wires in the electrical cord to the de-humidifier.

35. The Basement Accounts Payable Area revealed a Heater Unit located by the ceiling with exposed electrical wiring.

36. The Basement "Old Crawl Space" revealed an unapproved blue plastic flexible conduit used to enclose electrical wiring located by the Air Handler Unit.

37. The Basement Purchasing Office revealed 3 permanent ceiling lighting units that were not directly wired into an electrical junction box.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 Alcohol-Based Hand Rub in accordance with Section 19.3.2.7 of the 2000 Life Safety Code. This deficient practice would affect approximately 2 staff members. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Observation and interview on 1/3/12, revealed an Alcohol-Based Hand Rub installed directly over an electrical outlet located in the 100 Hall Nutrition Station. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 4 of approximately 100 doors within 4 of 6 smoke zones in proper working condition. This deficient practice would affect approximately 8 residents within the affected zones. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The 200 Hall Resident Room 205 revealed the corridor door was propped open with a towel.

2. The Medical Records Corridor Door revealed the door was warped and a space of approximately 1/2 inch was revealed between the door and the door frame when the door was in the closed position.

3. The CT Room revealed 2 of 2 doors that were detached from the door closers that were provided for the doors.

4. The 100 Hall Resident Room 106 revealed the corridor door was warped and revealed a space of approximately 1 inch located at the top of the door between the door and the door frame when the door was in the closed position.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain proper vertical fire separation in 3 of approximately 20 rooms within 2 of 6 smoke zones. This deficient practice could affect approximately 5 residents and approximately 10 staff members within the affected zones. The facility had a capacity of 26 residents and a census of 10 residents.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The North Nurse's Station revealed a vertical cable penetration (approximately 1 inch in size) located by the Security Monitor.

2. The North IV Room revealed a vertical duct penetration (approximately 1/2 inch in size) located in the ceiling lid.

3. The Basement Server Room revealed a vertical wire and cable bundle penetration (approximately 6 inches by 6 inches in size) located by the North wall.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide illuminated exit signs in 1 of 6 smoke zones to properly indicate the direction of travel to exit. This deficient practice would affect approximately 6 staff members. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the Basement Accounts Payable area was not provided with any exit signs to provide the proper direction to travel to an exit. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 of 6 smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects approximately 3 residents and 5 staff members within the affected zone. This facility has a capacity of 25 and a census of 10 residents.

Findings include:

Observation and interview on 1/3/12, revealed a pipe penetration (approximately 1/2 inch in size) located in the 400 Hall Smoke Barrier. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 of 6 sets of smoke barrier doors in proper working condition. This deficient practice would affect approximately 4 residents within the facility. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Observation and interview on 1/3/12, revealed the Fire Barrier Doors to the 300 Hall failed to close and latch properly into the door frame with the swing of the door closers when tested. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of 10 of approximately 15 hazardous areas, in 4 of 6 smoke zones, from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect approximately 10 residents within the affected zones. The facility had a capacity of 25 residents and a census of 10 residents.


Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The Surgery Central Supply Room revealed the door to the Operating Room 1 failed to close and latch properly into the door frame with the swing of the door closer when tested.

2. The Kitchen Pantry revealed the door was not provided with a door closer. This room was a storage room that was greater than 50 square feet in size.

3. The Laboratory revealed a wire penetration (approximately 1/2 inch in size) located in the South Wall.

4. The 300 Hall Storage Room 309 revealed the corridor door was not provided with a door closer device.

5. The 400 Hall Storage Room 4 revealed the corridor door failed to close and latch properly into the door frame with the swing of the door closer when tested.

6. The Boiler Room revealed 2 conduit penetrations (approximately 1/2 inch in size each) located in the East Wall above the door and a conduit penetration (approximately 1 inch in size) located above the East Wall Electrical Panels.

7. The Maintenance Office/Room revealed a conduit penetration (approximately 1/2 inch in size) located above the corridor door.

8. The Basement Elevator Equipment Room revealed rubber garden hose penetrations (approximately 1 inch in size each) in 2 walls within the room. This room also revealed a vertical conduit penetration (approximately 1/2 inch in size) located above the Master Electrical Switch.

9. The Basement "Old Crawl Space" revealed the corridor door was not provided with a door closer. This area is not sprinkled and contained multiple mechanical devices.

10. The Basement "Old Crawl Space" revealed multiple conduit and pipe penetrations (approximately 1 inch up to 4 feet in size) located in the corridor wall to the Accounts Payable Area and the Purchasing Storage Area.

11. The Purchasing Storage Area revealed the door from the Corridor and Accounts Payable Area had been removed.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 12 of approximately 100 rooms in 4 of 6 smoke zones with readily and easily accessible routes and means of egress. This deficient practice would affect approximately 10 residents within the affected zones. The facility had a capacity of 25 residents and census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The 200 Hall revealed tables, chairs, a bench, a tree, and a shelf located in the corridor that obstructed the width of the corridor.

2. The 200 Hall Activities Room revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

3. The Surgery Hallway Recovery Room revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

4. The Surgery Hall Operating Room 1 revealed revealed thumb-bolt latching devices on 2 of 2 doors that would require a tight grip, pinch, and twist to disengage the locks before opening the doors.

5. The Surgery Hall Operating Room 2 revealed a thumb-bolt latching device on the corridor door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

6. The Department of Education Director Office revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

7. The Laundry Room Corridor Door revealed the door hardware was installed at a height of over 5 feet off the ground.

8. The Kitchen Doors revealed thumb-bolt latching devices on the 3 of 3 entry doors that would require a tight grip, pinch, and twist to disengage the locks before opening the doors.

9. The Kitchen Pantry Door revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

10. The 400 Hall Waiting Area File Storage Room Door revealed a thumb-bolt latching device on the door that would require a tight grip, pinch, and twist to disengage the lock before opening the door.

11. The 400 Hall Mammogram Room revealed a Cage Storage Area that was equipped with a dead bolt lock that required a tight grip, pinch, and twist to disengage the lock mechanism.

12. The Basement Purchasing Storage Area revealed a gated fence with a door equipped with a dead bolt lock that required a tight grip, pinch, and twist to disengage the lock mechanism.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations, record review and interview, the facility failed to properly provide and maintain the emergency lighting units within the facility. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 1/3/12, revealed the following:

1. Record review and interview revealed the facility failed to provide the monthly 30 second testing and the annual 90 minute testing for the emergency lighting units throughout the facility. Interview with the Maintenance Staff A revealed the facility was unaware of this requirement.

2. The Surgery Hall Operating Room 1 revealed the room was not provided with an emergency lighting unit that was separate from the emergency generator to provide uninterrupted lighting in the event of a power failure.

3. The Surgery Hall Operating Room 2 revealed the room was not provided with an emergency lighting unit that was separate from the emergency generator to provide uninterrupted lighting in the event of a power failure.

4. The 400 Hall Direct Exit Door and Pathway revealed the path of egress was not provided with emergency lighting units to properly illuminate the path of egress to a public way in the event of a power failure.

5. The 100 Hall Direct Exit Door and Pathway revealed the path of egress was not provided with emergency lighting units to properly illuminate the path of egress to a public way in the event of a power failure.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 of 2 exit signs in 1 of 6 smoke zones in proper working condition. This deficient practice would affect approximately 2 residents within the affected zone. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Observation and interview on 1/3/12, revealed the exit sign located in the Pharmacy Hall to the CT Exit Door failed to be illuminated. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on record review and interview, the facility failed to provide 3 of 8 fire drills at varying times in 3 of 4 quarters on 1 of 2 staff shifts. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Record review and interview on 1/3/12, revealed the facility provided 3 of 4 fire drills on the Second Staff Shift (7 pm to 7 am) within the 5 a.m. hour. The 1st Quarter Fire Drill for the 2nd Shift was conducted at 0545, the 2nd Quarter Fire Drill for the 2nd Shift was conducted at 0520, and the 4th Quarter Fire Drill for the 2nd Shift was conducted at 0521. The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to maintain the building's fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition. This deficient practice would affect all residents throughout the building. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Record review and interview on 1/3/12, revealed the Fire Alarm Inspection Report did not provide a list of the locations or serial numbers of the initiating and supervisory devices that were tested. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's sprinkler system in 3 of 6 smoke zones accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect approximately 5 residents within the affected zones. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The Pharmacy Hall Isolation Cart Room revealed an excessive amount of dust and dirt on the sprinkler head (1 of 1 sprinkler head).

2. The Kitchen revealed an excessive amount of dust and dirt on 7 of 18 sprinkler heads within the Kitchen.

3. The Basement Maintenance Office/Room revealed the Spare Sprinkler Head Box was not equipped with a sprinkler head wrench.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 6 fire extinguishers in 5 of 6 smoke zones in accordance with the National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 1998 edition. This deficient practice would affect approximately 8 residents within the affected zone. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The Basement Server Room revealed the fire extinguisher was not mounted and was sitting on the ground behind the Corridor door.

2. The Maintenance Room revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

3. The 300 Hall Medical Records Room revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

4. The 300 Hall by the Fire Doors revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

5. The Financial Counselor's Office revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

6. The Front Main Entry Lobby revealed the fire extinguisher was mounted at a height of approximately 5 feet off the ground.

The Facility Maintenance Staff A confirmed this finding on the date of inspection

Based on observation and interview, the facility failed to provide proper venting and ductwork for 1 of 2 laundry areas in 1 of 6 smoke zones. This deficient practice would affect approximately 3 staff members. The facility had a capacity of 25 residents and a census of 10 residents on the date of inspection.

Findings include:

Observation and interview on 1/3/12, revealed the facility failed to provide proper venting for a clothes dryer unit located in the 300 Hall Laundry Area. At the time of inspection, the dryer in this area revealed the duct work terminated within the room and the top of the duct was covered with a hair-net used as a filter.

Based on observation and interview, the facility failed to provide proper signage for the storage of oxygen in 1 room in 1 of 6 smoke zones. This deficient practice would affect approximately 3 staff members and 3 residents within the affected zone. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Observation and interview on 1/3/12, revealed the 100 Hall Oxygen Storage Room failed to be provided with a sign indicating there was to be No-Smoking within the room. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on record review and interview, the facility failed to provide proper testing and documentation of the building's emergency generator in accordance with the National Fire Protection Association (NFPA) Standard 110, 1999 edition. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 25 residents and a census of 10 residents.

Findings include:

Record review and interview on 1/3/12, revealed the testing documentation of the Generator did not provide all required information required by the NFPA Standard 110, 1999 edition. At the time of inspection, the facility's Generator Testing Documentation only indicated the date, time, on/off, comments, and initials of the person completing the documentation. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's electrical system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect approximately 10 residents within the affected zones. The facility had a capacity of 25 residents and had a census of 10 residents on the date of inspection.

Findings include:

Observations and interview on 1/3/12, revealed the following:

1. The 200 Hall Respiratory Office revealed a refrigerator plugged into a surge protector.

2. The 200 Hall Resident Room 201 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

3. The 200 Hall Resident Room 202 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

4. The 200 Hall Resident Room 203 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

5. The 200 Hall Resident Room 204 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

6. The 200 Hall Resident Room 205 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

7. The 200 Hall Resident Room 206 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

8. The 200 Hall Resident Room 207 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

9. The 200 Hall Resident Room 208 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

10. The 200 Hall Linen Storage Area revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

11. The Surgery Hall revealed exposed electrical wires in a ceiling lighting unit located by the Smoke Barrier Doors.

12. The Surgery Hall Operating Room 1 revealed exposed electrical wires located behind the Clock on the wall..

13. The Pharmacy Hall CT Direct Exit revealed an open electrical junction box located on the exterior of the building.

14. The 100 Hall Resident Room 101 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

15. The 100 Hall Resident Room 102 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

16. The 100 Hall Resident Room 103 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

17. The 100 Hall Resident Room 104 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

18. The 100 Hall Resident Room 105 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

19. The 100 Hall Resident Room 106 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

20. The 100 Hall Resident Room 107 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

21. The 100 Hall Resident Room 108 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

22. The 100 Hall Resident Room 109 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

23. The 100 Hall Resident Room 110 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

24. The 100 Hall Resident Room 111 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

25. The 100 Hall Resident Room 112 revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

26. The 100 Hall Cart Storage Area revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

27. The 100 Hall Linen Storage Area revealed exposed electrical wires in the circular ceiling lighting unit located by the corridor door.

28. The 100 Hall IT Room revealed breakers in the Left Electrical Panel B were not properly labeled.

29. The Laundry Room Clean Linen Area revealed storage items within 3 feet of the electrical panel.

30. The Laundry Room revealed an open electrical junction box located behind the Air Handler Unit on the South Wall.

31. The 300 Hall Laundry Area revealed a refrigerator plugged into a plastic surge protector.

32. The 300 Hall Direct Exit by the Oxygen Storage Area revealed an electrical drop cord plugged into a bug zapper.

33. The Maintenance Room revealed a conduit not properly secured to a junction box that revealed exposed electrical wires located on the East wall by the door.

34. The Basement Elevator Equipment Room revealed exposed electrical wires in the electrical cord to the de-humidifier.

35. The Basement Accounts Payable Area revealed a Heater Unit located by the ceiling with exposed electrical wiring.

36. The Basement "Old Crawl Space" revealed an unapproved blue plastic flexible conduit used to enclose electrical wiring located by the Air Handler Unit.

37. The Basement Purchasing Office revealed 3 permanent ceiling lighting units that were not directly wired into an electrical junction box.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.