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Based on observation and interview on 02-25-16, the facility failed to maintain doors in smoke barriers to be rated and automatic closing. The smoke doors affected two of the three smoke compartments in the building. This deficient practice could affect all occupants, in this facility with a capacity of 12 and a census of 4.
Findings are:
1. Observation on 02-25-16 at approximately 1:20 P.M., while testing the smoke doors in the southeast corridor, it was observed that when the doors were closed there was a gap greater than 1/4 inch which would prevent the resistance to the passage of smoke.
2. During interview on 02-25-16 at approximately 1:20 P.M., with Maintenance staff A confirmed this observation during the survey process and advised that he was unaware that the allowable gap between the doors was 1/8 inch.
3. Observation on 02-25-16 at approximately 1:45 P.M., while testing the smoke doors in the northeast corridor by the treatment room, it was observed that when the doors were closed there was a gap greater than 1/4 inch which would prevent the resistance to the passage of smoke
4. During interview on 02-25-16 at approximately 1:45 P.M., with Maintenance staff A confirmed this observation during the survey process and advised that he was unaware that the allowable gap between the doors was 1/8 inch.

Based on observations on 02-25-16, the facility failed to maintain the fire resistive rating of doors protecting openings in a rated barrier wall. The deficient practice affected two of three smoke compartments, staff and 4 patients. The facility has the capacity for 12 beds with a census of 4 the day of the survey.
Findings are:
01) Observation on 02-25-16 at 2:30 P.M., the fire doors located between the patient floor and the medical clinic revealed that the doors were not smoke resistive with a gap between the doors when closed. The gap was 1/4" and 1/2" in size from the top to bottom.
02) During Interview on 02-25-16 at approximately 2:30 P.M., with Maintenance staff A revealed that the facility was not aware that the fire doors were not smoke resistive and confirmed this observation during the survey process.

Based on observation, on 02/25/16 the facility failed to maintain the use of relocatable power taps. Which are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.

General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. This facility has a census of 4 with a capacity of 12.
Findings are:

1. Observation on 02-25-16 at approximately 2:05 P.M., revealed a yellow extension multi outlet power adaptor plugged into a duplex receptacle along the east wall of the bone density room. The bone density controls were plugged into this power adaptor at the time of this observation.
2. During interview on 02-25-16 at approximately 2:05 P.M., with Maintenance staff A confirmed this observation during the survey process.

Based on observation and interview on 02-25-16, the facility failed to maintain doors in smoke barriers to be rated and automatic closing. The smoke doors affected two of the three smoke compartments in the building. This deficient practice could affect all occupants, in this facility with a capacity of 12 and a census of 4.
Findings are:
1. Observation on 02-25-16 at approximately 1:20 P.M., while testing the smoke doors in the southeast corridor, it was observed that when the doors were closed there was a gap greater than 1/4 inch which would prevent the resistance to the passage of smoke.
2. During interview on 02-25-16 at approximately 1:20 P.M., with Maintenance staff A confirmed this observation during the survey process and advised that he was unaware that the allowable gap between the doors was 1/8 inch.
3. Observation on 02-25-16 at approximately 1:45 P.M., while testing the smoke doors in the northeast corridor by the treatment room, it was observed that when the doors were closed there was a gap greater than 1/4 inch which would prevent the resistance to the passage of smoke
4. During interview on 02-25-16 at approximately 1:45 P.M., with Maintenance staff A confirmed this observation during the survey process and advised that he was unaware that the allowable gap between the doors was 1/8 inch.

Based on observations on 02-25-16, the facility failed to maintain the fire resistive rating of doors protecting openings in a rated barrier wall. The deficient practice affected two of three smoke compartments, staff and 4 patients. The facility has the capacity for 12 beds with a census of 4 the day of the survey.
Findings are:
01) Observation on 02-25-16 at 2:30 P.M., the fire doors located between the patient floor and the medical clinic revealed that the doors were not smoke resistive with a gap between the doors when closed. The gap was 1/4" and 1/2" in size from the top to bottom.
02) During Interview on 02-25-16 at approximately 2:30 P.M., with Maintenance staff A revealed that the facility was not aware that the fire doors were not smoke resistive and confirmed this observation during the survey process.

Based on observation, on 02/25/16 the facility failed to maintain the use of relocatable power taps. Which are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.

General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. This facility has a census of 4 with a capacity of 12.
Findings are:

1. Observation on 02-25-16 at approximately 2:05 P.M., revealed a yellow extension multi outlet power adaptor plugged into a duplex receptacle along the east wall of the bone density room. The bone density controls were plugged into this power adaptor at the time of this observation.
2. During interview on 02-25-16 at approximately 2:05 P.M., with Maintenance staff A confirmed this observation during the survey process.