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Based on surveyor observation and staff interview, the facility failed to provide smoke barrier doors that resist the passage of smoke. This deficient practice affects 2 of 12 smoke zones in the facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed an approximately 1/2-inch gap between the smoke doors in the Employee Hallway when the doors were in the closed position.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to separate hazardous areas from the rest of the building. This deficient practice affects 1 of 12 smoke zones in the facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed an approximately 4-inch cable sleeve passing through the corridor wall above the door to the Main Mechanical Room that was not filled with a fire-resistant material.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the battery emergency lights. This deficient practice affects 11 of 11 smoke zones in facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed the following emergency light deficiencies:

1. The facility failed to document monthly (30 second) and annual (90 minute) tests of the battery emergency lights.
2. The emergency light located by Office 4 in the Nevada Medical Clinic failed to function when tested.
3. The emergency light located in the Waiting Area in the Slater Medical Clinic failed to function when tested.
4. The emergency light located by Room 5 in the Slater Medical Clinic failed to function when tested.
5. The emergency light located in the North Hall in the Slater Medical Clinic failed to function when tested.
6. The emergency light located by the Laboratory in the Maxwell Medical Clinic failed to function when tested.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the illuminated exit signs. This deficient practice affects 1 of 1 smoke zones in an off-site facility. The facility has a capacity of 17 and a census of 11.

Finding include:

Observations and staff interview on 12/20/13 revealed the northwest exit sign in the Slater Medical Clinic was not illuminated.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25. This deficient practice affects 1 of 1 smoke zones in an off-site facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed storage in the Storage Room located across from Exam 10 within 18-inches of the sprinkler head.

Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to maintain the fire extinguishers in accordance with National Fire Protection Association (NFPA) 10. This deficient practice affects 1 of 1 smoke zones in 2 off-site facilities. The facility has a capacity of 17 and a census of 11.

Findings include:

Observation and staff interview on 12/20/13 revealed the following fire extinguisher deficiencies:

1. The fire extinguishers located in the Slater Medical Clinic were last inspected in September of 2012 instead of annually as required.
2. The fire extinguishers located in the Maxwell Medical Clinic were last inspected in September of 2012 instead of annually as required.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain all exits free of obstructions. This deficient practice affects 1 of 1 smoke zone in an off-site facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed storage obstructing the south exit from the Maxwell Medical Clinic.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70. This deficient practice affects 1 of 12 smoke zones in the facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed a refrigerator in the "Omnicell" Room that was plugged into a multi-plug electrical strip.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to provide smoke barrier doors that resist the passage of smoke. This deficient practice affects 2 of 12 smoke zones in the facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed an approximately 1/2-inch gap between the smoke doors in the Employee Hallway when the doors were in the closed position.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to separate hazardous areas from the rest of the building. This deficient practice affects 1 of 12 smoke zones in the facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed an approximately 4-inch cable sleeve passing through the corridor wall above the door to the Main Mechanical Room that was not filled with a fire-resistant material.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the battery emergency lights. This deficient practice affects 11 of 11 smoke zones in facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed the following emergency light deficiencies:

1. The facility failed to document monthly (30 second) and annual (90 minute) tests of the battery emergency lights.
2. The emergency light located by Office 4 in the Nevada Medical Clinic failed to function when tested.
3. The emergency light located in the Waiting Area in the Slater Medical Clinic failed to function when tested.
4. The emergency light located by Room 5 in the Slater Medical Clinic failed to function when tested.
5. The emergency light located in the North Hall in the Slater Medical Clinic failed to function when tested.
6. The emergency light located by the Laboratory in the Maxwell Medical Clinic failed to function when tested.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the illuminated exit signs. This deficient practice affects 1 of 1 smoke zones in an off-site facility. The facility has a capacity of 17 and a census of 11.

Finding include:

Observations and staff interview on 12/20/13 revealed the northwest exit sign in the Slater Medical Clinic was not illuminated.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25. This deficient practice affects 1 of 1 smoke zones in an off-site facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed storage in the Storage Room located across from Exam 10 within 18-inches of the sprinkler head.

Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to maintain the fire extinguishers in accordance with National Fire Protection Association (NFPA) 10. This deficient practice affects 1 of 1 smoke zones in 2 off-site facilities. The facility has a capacity of 17 and a census of 11.

Findings include:

Observation and staff interview on 12/20/13 revealed the following fire extinguisher deficiencies:

1. The fire extinguishers located in the Slater Medical Clinic were last inspected in September of 2012 instead of annually as required.
2. The fire extinguishers located in the Maxwell Medical Clinic were last inspected in September of 2012 instead of annually as required.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain all exits free of obstructions. This deficient practice affects 1 of 1 smoke zone in an off-site facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed storage obstructing the south exit from the Maxwell Medical Clinic.

Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70. This deficient practice affects 1 of 12 smoke zones in the facility. The facility has a capacity of 17 and a census of 11.

Findings include:

Observations and staff interview on 12/20/13 revealed a refrigerator in the "Omnicell" Room that was plugged into a multi-plug electrical strip.

Administrative Staff A and Maintenance Staff A observed this finding.