HospitalInspections.org

Based on observations, it was determined the facility was a two-story building composed of fire resistive construction (concrete and steel). The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed. The facility has a capacity of 25 residents and that time of the survey had a census of 16.

Findings include:

1. Observations on 11/09/10, revealed a gap (approximately 1/2 inch in size) around a flex conduit penetration in the corridor wall of Medical Records.

2. Observations on 11/09/10, revealed gaps and holes (approximately 1/4 inch to 4 inches in size) in the ceiling of the Elevator Equipment Room.

3. Observations on 11/09/10, revealed a displaced ceiling tile in the Audiovisual Closet in the Board Room.

4. Observations on 11/09/10, revealed hole (approximately 2 inches in size) above the door closure in the ICU Room 203.

5. Observations on 11/09/10, revealed multiple holes and gaps around penetrations, ranging in approximate size from 1 inch to 4 inches, in the corridor wall of the second floor Phone Room.

6. Observations on 11/09/10, revealed missing ceiling tile in the Radiology Office.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice would not prevent the spread of fire and smoke. The facility has a capacity for 25 and at the time of the survey the census was 16.

Findings include:

1. Observations on 11/09/10, revealed the corridor door to Room 214 did not latch properly when tested.

2. Observations on 11/09/10, revealed the corridor door to the Clean Utility Room did not latch properly when tested.

3. Observations on 11/09/10, revealed the corridor door to Room 242 did not latch properly when tested.

4. Observations on 11/09/10, revealed the 90 minute fire door into the Outpatient Center by ER did not latch properly when tested.

5. Observations on 11/09/10, revealed a missing strike plate on the door frame to the Elevator Equipment Room.

Based on observations, this facility is not assuring the east stairway connecting the first and second floors is free of penetrations that compromise the fire-resistance rating and allow the passage of smoke and fire into the stairway. This facility has a capacity of 25 and a census of 16 residents.

Findings include:

1. Observations on 11/09/10, revealed a gap (approximately 1/4 inch in size) around a conduit penetration on the first floor of the East Stairway.

2. Observations on 11/09/10, revealed a hole (approximately 1 inch in size) above the second floor door in the East Stairway.

3. Observations on 11/09/10, revealed the second floor East Stairway door did not latch properly when tested.

Based on observations, 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 fire rated construction equipped with a partial sprinkler system. The doors shall be self-closing or automatic-closing. The facility has a capacity for 25 and at the time of the survey the census was 16.

Findings include:

1. Observations on 11/09/10, revealed a gap, approximately 2 inches in size, between the wall used to separate the Boiler Room and Medical Records and the horizontal beam. The gap had been sealed with insulation, however in many areas the insulation had been removed creating holes approximately 2 inches to 12 inches in size.

2. Observations on 11/09/10, revealed a gap (approximately 4 inches in size) around a pipe penetration in the wall separating the Bio Hazard Storage Room and the Boiler Room.

3. Observations on 11/09/10, revealed the corridor door to the Linen Finishing Room did not close and latch properly when tested.

4. Observations on 11/09/10, revealed missing ceiling tile and gaps (approximately 1/4 inch to 2 inches in size) around penetrations through the ceiling tile in the dirty side of the Laundry Room.

Based on observations, the facility is not ensuring that doors to hazardous rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice would not prevent the spread of fire and smoke. The facility has a capacity for 25 and at the time of the survey the census was 16.

Findings include:

1. Observations on 11/09/10, revealed the corridor door to the Janitor's Closet by Hand Therapy did not latch properly when tested.

(A)
Based on observations, the facility is not providing unobstructed exits that provides a clear path of egress from the building. This deficient practice affects occupants of the Maintenance Department. This facility has a capacity of 25 with a census of 16.

Findings include:

Observations on 11/09/10, revealed the exit door from the Garage did not open properly at the time of the survey. Observations showed wheelchairs and buckets had been stored outside the exit door preventing the door from opening properly.

(B)
Based on observation, the facility failed to maintain exits readily accessible at all times in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 7.1. Doors shall be arranged to be opened readily from the egress side when ever the building is occupied. Locks, if provided shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. The facility has a capacity of 25 and at the time of the survey the census was 16.

Findings include:

Observations on 11/09/10, revealed the doorknob on the door to into the back hallway of Dialysis had been installed with the key operated side on the egress side of the door. Observations showed if this door was locked it required a key to unlock the door from the egress side.

(C)
Based on observations, the facility failed to maintain exits readily accessible at all times in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 7.2.1.4.3. A door shall swing in the direction of egress travel where used in an exit enclosure. The facility has a capacity of 25 and at the time of the survey had a census of 16.

Findings include:

Observations on 11/09/10, revealed the doors leading from the corridor through the Loading Dock swung against the direction of egress travel.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. This facility has a capacity of 25 and a census of 16.

Findings include:

1. Record review of the facility's maintenance records on 11/09/10, revealed no documentation of the annual 1 1/2 hour test.

2. Record review of the facility's maintenance records on 11/09/10, revealed the facility was unable to provide documentation showing the battery operated emergency light units had been tested in the months of June, July, August, September, and October in 2010. Also absent in the documentation was the duration of the test.

3. Observations on 11/09/10, revealed the emergency light unit in Trauma 1 in ER did not operate properly when tested.

Based on observations, the facility failed to install exit signs in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition. Exits shall be marked by an approved sign readily visible from any direction of exit access. The facility has a capacity of 25 and at the time of the survey the census was 16.

Findings include:

1. Observations on 11/09/10, revealed an exit sign had not been installed above the doors to the Loading Dock.

2. Obervations on 11/09/10, revealed a directional exit sign had not been installed to direct occupants from the elevator toward the east exit door on the second floor.

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 25 with a census of 16.

Findings include:

Record review on 11/09/10, revealed the facility fire drill documentation showed all of the first shift drills were conducted between 12:20 p.m. and 1:55 p.m. during the last 12 months.

(A)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the building. The facility has a capacity of 25 and at the time of the survey had a census of 16 residents.

Findings include:

Record review of the fire alarm test records on 11/09/10, revealed the initiating and supervisory devices were not documented as being inspected or tested in accordance with the frequencies established in NFPA 72. Record review showed 0 of 20 manual pull stations were inspected or tested during the fire alarm inspection conducted on 2/8/10, and on the 7/16/10 inspection report 3 manual pull stations were listed as being tested but the locations were not documented in the initiating and supervisory device test and inspections section of the report.

Record review also showed the only items listed in the initiating and supervisory device test and inspection section of the report on 7/16/10 were the batteries, and flow and tamper switches. Absent were the list of the remaining initiating devices.

Review of the 2/8/10 inspection report showed nothing had been documented in the section "System Power Supply" along with nothing documented on the testing and inspection of the fire alarm control panel. Review of the 7/16/10 inspection report showed the backup batteries were listed as being tested and inspected and a visual inspection of the fire alarm system was conducted.

(B)
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 ceiling fan can impede the operation of the smoke detector. This facility has a capacity of 25 and a census of 16.

Findings include:

Observations on 11/09/10, revealed a smoke detector had been installed within 3 feet of the HVAC system in Mammography.

Based on observations, the facility failed to provide a properly maintained fire alarm system. Also, 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 ceiling fan can impede the operation of the smoke detector. The deficient practice could affect all occupants of the facility. The facility has a capacity of 25 and at the time of the survey had a census of 16.

Findings include:

1. Observations on 11/09/10, revealed decorations had been placed in front of the fire alarm control unit obstructing access and vision of the panel.

2. Observations on 11/09/10, revealed a smoke detector had been installed within 36 inches of the air return in Cardiac Rehab.

Based on record review, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 16.

Findings include:

1. During the record review of the facilities fire safety components on 11/09/10, revealed the facility was unable to provide documentation showing the sprinkler system had been provided with a quarterly inspection for the fourth quarter in 2009. Record review also showed the completed quarterly inspection reports failed to include documentation of the inspection of the hydraulic name plate and the inspection of the alarm devices to ensure they were free of physical damage.

2. Record review of the sprinkler system maintenance records on 11/09/10, revealed the following deficiencies had been noted: "No gauges on system to see what residual pressure is" and "Drain off the preaction system too small, should be increased to 1-inch pipe, not sure where drain pipe drains to". Maintenance staff reported system drains outside. Observations showed only one gauge on the sprinkler system prior to the backflow preventer.

3. Record review on 11/09/10, revealed no flow pressure had been documented for the main drain test during the annual inspection of the sprinkler system conducted on 9/14/10.

4. Observations on 11/09/10, revealed the sprinkler head in the bathroom located by the Board Room had been painted and had not been replaced.

5. Observations on 11/09/10, revealed dirt/foreign debris on the sprinkler head in the Dialysis Clinic.

6. Observations on 11/09/10, revealed a missing escutcheon ring around the sprinkler head in the first floor Janitor's Closet across from the Kitchen.

7. Observations on 11/09/10, revealed a missing escutcheon ring around the sprinkler head in the Kitchenette in the second floor Waiting Room.

8. Observations on 11/09/10, revealed a wire had been wrapped around the sprinkler pipe in the Ambulance Garage.

Based on observations, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. When an inspection of any fire extinguisher reveals a deficiency in any of the conditions listed within the standard, immediate corrective action shall be taken. The facility has a capacity of 25 and at the time of the survey had a census of 16.

Findings include:

Observations on 11/09/10, revealed the gauge on the fire extinguisher in the Boiler Room indicated overcharge.

Based on record review, the facility failed to maintain the hood and fire-extinguishing equipment in accordance with National Fire Protection Association (NFPA) Standard 96, the standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition, 7-6.2. Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the automatic fire-extinguishing system shall activated the fire alarm signaling system. NFPA 72 requires this interconnection to be inspected semi-annually and tested annually. Also the facility failed to inspect and test the hood and fire-extinguishing equipment in accordance with National Fire Protection Association (NFPA) Standard 96, the standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition. Penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld. This deficient practice affects all occupants of the facility. The facility has a capacity of 25 and at the time of the survey had a census of 16 residents.

Findings include:

1. Record review of the inspection report of the hood and duct system on 11/09/10, revealed the following deficiency had been noted on the 1/6/10 inspection report: "Not connected to the bldg fire alarm system."

2. Record review on 11/09/10, revealed the facility was unable to provide documentation showing the system had been inspected semi-annually as required. The only inspection report provided was dated 1/6/10.

3. Observations on 11/09/10, revealed gaps (approximately 1/4 inch to 1 inch in size) around pipe penetrations through the hood above the commercial cooking appliance in the Kitchen.

Based on observation, the facility failed to provide emergency task illumination at the emergency generator location. The emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 16.

Findings include:

Observation on 11/09/10, revealed a battery emergency light unit was not provided at the emergency generator location to provide task illumination. Maintenance Staff A confirmed observation during the survey process.

Based on observations, 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. This facility has a capacity of 25 and a census of 16.

Findings include:

1. Observations on 11/09/10, revealed storage in front of the electrical panel in the Dialysis Clinic Electrical Room.

2. Observations on 11/09/10, revealed exposed electrical wiring to the power strip on the wall of the Dialysis Clinic Electrical Room.

3. Observations on 11/09/10, revealed storage in front of the electrical panel in the Electrical Utility Room of Radiology.

Based on observations, it was determined the facility was a two-story building composed of fire resistive construction (concrete and steel). The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed. The facility has a capacity of 25 residents and that time of the survey had a census of 16.

Findings include:

1. Observations on 11/09/10, revealed a gap (approximately 1/2 inch in size) around a flex conduit penetration in the corridor wall of Medical Records.

2. Observations on 11/09/10, revealed gaps and holes (approximately 1/4 inch to 4 inches in size) in the ceiling of the Elevator Equipment Room.

3. Observations on 11/09/10, revealed a displaced ceiling tile in the Audiovisual Closet in the Board Room.

4. Observations on 11/09/10, revealed hole (approximately 2 inches in size) above the door closure in the ICU Room 203.

5. Observations on 11/09/10, revealed multiple holes and gaps around penetrations, ranging in approximate size from 1 inch to 4 inches, in the corridor wall of the second floor Phone Room.

6. Observations on 11/09/10, revealed missing ceiling tile in the Radiology Office.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice would not prevent the spread of fire and smoke. The facility has a capacity for 25 and at the time of the survey the census was 16.

Findings include:

1. Observations on 11/09/10, revealed the corridor door to Room 214 did not latch properly when tested.

2. Observations on 11/09/10, revealed the corridor door to the Clean Utility Room did not latch properly when tested.

3. Observations on 11/09/10, revealed the corridor door to Room 242 did not latch properly when tested.

4. Observations on 11/09/10, revealed the 90 minute fire door into the Outpatient Center by ER did not latch properly when tested.

5. Observations on 11/09/10, revealed a missing strike plate on the door frame to the Elevator Equipment Room.

Based on observations, this facility is not assuring the east stairway connecting the first and second floors is free of penetrations that compromise the fire-resistance rating and allow the passage of smoke and fire into the stairway. This facility has a capacity of 25 and a census of 16 residents.

Findings include:

1. Observations on 11/09/10, revealed a gap (approximately 1/4 inch in size) around a conduit penetration on the first floor of the East Stairway.

2. Observations on 11/09/10, revealed a hole (approximately 1 inch in size) above the second floor door in the East Stairway.

3. Observations on 11/09/10, revealed the second floor East Stairway door did not latch properly when tested.

Based on observations, 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 fire rated construction equipped with a partial sprinkler system. The doors shall be self-closing or automatic-closing. The facility has a capacity for 25 and at the time of the survey the census was 16.

Findings include:

1. Observations on 11/09/10, revealed a gap, approximately 2 inches in size, between the wall used to separate the Boiler Room and Medical Records and the horizontal beam. The gap had been sealed with insulation, however in many areas the insulation had been removed creating holes approximately 2 inches to 12 inches in size.

2. Observations on 11/09/10, revealed a gap (approximately 4 inches in size) around a pipe penetration in the wall separating the Bio Hazard Storage Room and the Boiler Room.

3. Observations on 11/09/10, revealed the corridor door to the Linen Finishing Room did not close and latch properly when tested.

4. Observations on 11/09/10, revealed missing ceiling tile and gaps (approximately 1/4 inch to 2 inches in size) around penetrations through the ceiling tile in the dirty side of the Laundry Room.

Based on observations, the facility is not ensuring that doors to hazardous rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice would not prevent the spread of fire and smoke. The facility has a capacity for 25 and at the time of the survey the census was 16.

Findings include:

1. Observations on 11/09/10, revealed the corridor door to the Janitor's Closet by Hand Therapy did not latch properly when tested.

(A)
Based on observations, the facility is not providing unobstructed exits that provides a clear path of egress from the building. This deficient practice affects occupants of the Maintenance Department. This facility has a capacity of 25 with a census of 16.

Findings include:

Observations on 11/09/10, revealed the exit door from the Garage did not open properly at the time of the survey. Observations showed wheelchairs and buckets had been stored outside the exit door preventing the door from opening properly.

(B)
Based on observation, the facility failed to maintain exits readily accessible at all times in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 7.1. Doors shall be arranged to be opened readily from the egress side when ever the building is occupied. Locks, if provided shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. The facility has a capacity of 25 and at the time of the survey the census was 16.

Findings include:

Observations on 11/09/10, revealed the doorknob on the door to into the back hallway of Dialysis had been installed with the key operated side on the egress side of the door. Observations showed if this door was locked it required a key to unlock the door from the egress side.

(C)
Based on observations, the facility failed to maintain exits readily accessible at all times in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 7.2.1.4.3. A door shall swing in the direction of egress travel where used in an exit enclosure. The facility has a capacity of 25 and at the time of the survey had a census of 16.

Findings include:

Observations on 11/09/10, revealed the doors leading from the corridor through the Loading Dock swung against the direction of egress travel.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. This facility has a capacity of 25 and a census of 16.

Findings include:

1. Record review of the facility's maintenance records on 11/09/10, revealed no documentation of the annual 1 1/2 hour test.

2. Record review of the facility's maintenance records on 11/09/10, revealed the facility was unable to provide documentation showing the battery operated emergency light units had been tested in the months of June, July, August, September, and October in 2010. Also absent in the documentation was the duration of the test.

3. Observations on 11/09/10, revealed the emergency light unit in Trauma 1 in ER did not operate properly when tested.

Based on observations, the facility failed to install exit signs in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition. Exits shall be marked by an approved sign readily visible from any direction of exit access. The facility has a capacity of 25 and at the time of the survey the census was 16.

Findings include:

1. Observations on 11/09/10, revealed an exit sign had not been installed above the doors to the Loading Dock.

2. Obervations on 11/09/10, revealed a directional exit sign had not been installed to direct occupants from the elevator toward the east exit door on the second floor.

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 25 with a census of 16.

Findings include:

Record review on 11/09/10, revealed the facility fire drill documentation showed all of the first shift drills were conducted between 12:20 p.m. and 1:55 p.m. during the last 12 months.

(A)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the building. The facility has a capacity of 25 and at the time of the survey had a census of 16 residents.

Findings include:

Record review of the fire alarm test records on 11/09/10, revealed the initiating and supervisory devices were not documented as being inspected or tested in accordance with the frequencies established in NFPA 72. Record review showed 0 of 20 manual pull stations were inspected or tested during the fire alarm inspection conducted on 2/8/10, and on the 7/16/10 inspection report 3 manual pull stations were listed as being tested but the locations were not documented in the initiating and supervisory device test and inspections section of the report.

Record review also showed the only items listed in the initiating and supervisory device test and inspection section of the report on 7/16/10 were the batteries, and flow and tamper switches. Absent were the list of the remaining initiating devices.

Review of the 2/8/10 inspection report showed nothing had been documented in the section "System Power Supply" along with nothing documented on the testing and inspection of the fire alarm control panel. Review of the 7/16/10 inspection report showed the backup batteries were listed as being tested and inspected and a visual inspection of the fire alarm system was conducted.

(B)
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 ceiling fan can impede the operation of the smoke detector. This facility has a capacity of 25 and a census of 16.

Findings include:

Observations on 11/09/10, revealed a smoke detector had been installed within 3 feet of the HVAC system in Mammography.

Based on observations, the facility failed to provide a properly maintained fire alarm system. Also, 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 ceiling fan can impede the operation of the smoke detector. The deficient practice could affect all occupants of the facility. The facility has a capacity of 25 and at the time of the survey had a census of 16.

Findings include:

1. Observations on 11/09/10, revealed decorations had been placed in front of the fire alarm control unit obstructing access and vision of the panel.

2. Observations on 11/09/10, revealed a smoke detector had been installed within 36 inches of the air return in Cardiac Rehab.

Based on record review, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 16.

Findings include:

1. During the record review of the facilities fire safety components on 11/09/10, revealed the facility was unable to provide documentation showing the sprinkler system had been provided with a quarterly inspection for the fourth quarter in 2009. Record review also showed the completed quarterly inspection reports failed to include documentation of the inspection of the hydraulic name plate and the inspection of the alarm devices to ensure they were free of physical damage.

2. Record review of the sprinkler system maintenance records on 11/09/10, revealed the following deficiencies had been noted: "No gauges on system to see what residual pressure is" and "Drain off the preaction system too small, should be increased to 1-inch pipe, not sure where drain pipe drains to". Maintenance staff reported system drains outside. Observations showed only one gauge on the sprinkler system prior to the backflow preventer.

3. Record review on 11/09/10, revealed no flow pressure had been documented for the main drain test during the annual inspection of the sprinkler system conducted on 9/14/10.

4. Observations on 11/09/10, revealed the sprinkler head in the bathroom located by the Board Room had been painted and had not been replaced.

5. Observations on 11/09/10, revealed dirt/foreign debris on the sprinkler head in the Dialysis Clinic.

6. Observations on 11/09/10, revealed a missing escutcheon ring around the sprinkler head in the first floor Janitor's Closet across from the Kitchen.

7. Observations on 11/09/10, revealed a missing escutcheon ring around the sprinkler head in the Kitchenette in the second floor Waiting Room.

8. Observations on 11/09/10, revealed a wire had been wrapped around the sprinkler pipe in the Ambulance Garage.

Based on observations, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. When an inspection of any fire extinguisher reveals a deficiency in any of the conditions listed within the standard, immediate corrective action shall be taken. The facility has a capacity of 25 and at the time of the survey had a census of 16.

Findings include:

Observations on 11/09/10, revealed the gauge on the fire extinguisher in the Boiler Room indicated overcharge.

Based on record review, the facility failed to maintain the hood and fire-extinguishing equipment in accordance with National Fire Protection Association (NFPA) Standard 96, the standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition, 7-6.2. Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the automatic fire-extinguishing system shall activated the fire alarm signaling system. NFPA 72 requires this interconnection to be inspected semi-annually and tested annually. Also the facility failed to inspect and test the hood and fire-extinguishing equipment in accordance with National Fire Protection Association (NFPA) Standard 96, the standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition. Penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld. This deficient practice affects all occupants of the facility. The facility has a capacity of 25 and at the time of the survey had a census of 16 residents.

Findings include:

1. Record review of the inspection report of the hood and duct system on 11/09/10, revealed the following deficiency had been noted on the 1/6/10 inspection report: "Not connected to the bldg fire alarm system."

2. Record review on 11/09/10, revealed the facility was unable to provide documentation showing the system had been inspected semi-annually as required. The only inspection report provided was dated 1/6/10.

3. Observations on 11/09/10, revealed gaps (approximately 1/4 inch to 1 inch in size) around pipe penetrations through the hood above the commercial cooking appliance in the Kitchen.

Based on observation, the facility failed to provide emergency task illumination at the emergency generator location. The emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 16.

Findings include:

Observation on 11/09/10, revealed a battery emergency light unit was not provided at the emergency generator location to provide task illumination. Maintenance Staff A confirmed observation during the survey process.

Based on observations, 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. This facility has a capacity of 25 and a census of 16.

Findings include:

1. Observations on 11/09/10, revealed storage in front of the electrical panel in the Dialysis Clinic Electrical Room.

2. Observations on 11/09/10, revealed exposed electrical wiring to the power strip on the wall of the Dialysis Clinic Electrical Room.

3. Observations on 11/09/10, revealed storage in front of the electrical panel in the Electrical Utility Room of Radiology.