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Observations and testing of approximately 50 corridor doors revealed that the facility staff failed to maintain 3 corridor door in accordance with NFPA 101 The Life Safety Code 2000 edition, section 18.3.6.3. This deficient practice could affect the safety of all patients, staff and visitors, if smoke were allowed to enter the exit access corridor making it untenable.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that the corridor doors to rooms 513, 516 and 522 did not latch and stay tightly closed.

The Director of Maintenance (MC) verified this finding during the inspection and at the exit conference.

Observations revealed that the main kitchen is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1 (Hazardous Areas). This deficient practice could allow the products of combustion to travel from the kitchen to other areas if a fire occurs within this hazardous area and could negatively impact all patients, visitors and staff.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that the kitchen doors are no longer self-closing and one was improperly held open with a wedge which prevented the door from closing.

The Director of Maintenance (MC) verified this finding during the inspection and at the exit conference.

Observations and an interview with staff of all the exiting revealed that the exits from the basement level training room (A previous shell space) do not comply with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.2.1.6.1. This deficient practice could negatively affect all staff and visitors if it needs to be quickly evacuated the facility.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that:

1) The exiting from the basement training room (a previous shell space) are not in accordance with LSC section 7.5.1.3. The rooms calculated occupant load is over 50, is not posted and requires two exits (all doors open into the same corridor).

2) The doors leading into the existing nursing home building that are locked preventing entrance are not labeled NO EXIT as required by LSC section 7.10.8.1.

The Director of Maintenance (MC) verified these findings during the inspection and at the exit conference.

No documentation was available for review to insure that the fire alarm system has been tested in accordance with NFPA 72 "The National Fire Alarm Code" 2000 edition section 9.6.1.4. This deficient practice could allow the system to fail in a fire, which could negatively affect the safety of all patients, staff and visitors of the facility.

Findings include:
Prior to the facility tour on February 7, 2013, at approximately 2:00 pm, no documentation was available for review of the fire alarm system testing for the Deer River Meridian Medical Clinic Building.

The Director of Maintenance (MC) verified this finding during the inspection and at the exit conference.

Observations revealed that the automatic fire sprinkler system is not maintained in accordance with NFPA 25 Standard for Inspection, Testing and Maintenance of a Water-Based Fire protection System, 1998 edition. This deficient practice may allow a fire to grow which will negatively impact all the patients, visitors and staff.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that:

1) It could not be documented that the fire sprinkler system gauges have been replace or recalibrated within the past 5 years in accordance with NFPA 25 section 6-3.6, and

2) The boiler room is not separated from the rest of the building with 2-hour fire rated construction (one door was labeled 1-hour not 1 1/2- hour) and is Type II (000) construction, and no documentation of the suspended ceiling system in the 1973 addition, indicating a 1-hour fire rating was available, the entire building is Type II (000) construction and the entire building is required to be protected by a fire sprinkler system in accordance with NFPA 101 "The Life Safety Code" 2000 edition table 19.1.6.2. Areas not protected with fire sprinkler system include the 1973 addition, the cardiac care area and the kitchen/ dietary rooms.

The Director of Maintenance (MC) verified these findings during the inspection and at the exit conference.

No documentation was available for review to insure that the automatic fire sprinkler system has not been maintained in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 1999 edition section 9.7.5. This deficient practice could allow the system to fail in a fire, which could negatively affect the safety of all patients, staff and visitors of the facility.

Findings include:
Prior to the facility tour on February 7, 2013, at approximately 2:00 pm, no documentation was available for review of the automatic fire sprinkler system testing for the Deer River Meridian Medical Clinic Building.

The Director of Maintenance (MC) verified this finding during the inspection and at the exit conference.

Observations revealed that some electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. This deficiency could negatively effect the any staff and visitors in this area of the facility.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that:

1) An electrical extension cord has been run through the door way into the corridor from the basement level training room, and

2) Power taps have been plugged into another power tap and then into an extension cord in the basement training room.

The Director of Maintenance (MC) verified these findings during the inspection and at the exit conference.

Observations and testing of approximately 50 corridor doors revealed that the facility staff failed to maintain 3 corridor door in accordance with NFPA 101 The Life Safety Code 2000 edition, section 18.3.6.3. This deficient practice could affect the safety of all patients, staff and visitors, if smoke were allowed to enter the exit access corridor making it untenable.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that the corridor doors to rooms 513, 516 and 522 did not latch and stay tightly closed.

The Director of Maintenance (MC) verified this finding during the inspection and at the exit conference.

Observations revealed that the main kitchen is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.2.1 (Hazardous Areas). This deficient practice could allow the products of combustion to travel from the kitchen to other areas if a fire occurs within this hazardous area and could negatively impact all patients, visitors and staff.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that the kitchen doors are no longer self-closing and one was improperly held open with a wedge which prevented the door from closing.

The Director of Maintenance (MC) verified this finding during the inspection and at the exit conference.

Observations and an interview with staff of all the exiting revealed that the exits from the basement level training room (A previous shell space) do not comply with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.2.1.6.1. This deficient practice could negatively affect all staff and visitors if it needs to be quickly evacuated the facility.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that:

1) The exiting from the basement training room (a previous shell space) are not in accordance with LSC section 7.5.1.3. The rooms calculated occupant load is over 50, is not posted and requires two exits (all doors open into the same corridor).

2) The doors leading into the existing nursing home building that are locked preventing entrance are not labeled NO EXIT as required by LSC section 7.10.8.1.

The Director of Maintenance (MC) verified these findings during the inspection and at the exit conference.

No documentation was available for review to insure that the fire alarm system has been tested in accordance with NFPA 72 "The National Fire Alarm Code" 2000 edition section 9.6.1.4. This deficient practice could allow the system to fail in a fire, which could negatively affect the safety of all patients, staff and visitors of the facility.

Findings include:
Prior to the facility tour on February 7, 2013, at approximately 2:00 pm, no documentation was available for review of the fire alarm system testing for the Deer River Meridian Medical Clinic Building.

The Director of Maintenance (MC) verified this finding during the inspection and at the exit conference.

Observations revealed that the automatic fire sprinkler system is not maintained in accordance with NFPA 25 Standard for Inspection, Testing and Maintenance of a Water-Based Fire protection System, 1998 edition. This deficient practice may allow a fire to grow which will negatively impact all the patients, visitors and staff.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that:

1) It could not be documented that the fire sprinkler system gauges have been replace or recalibrated within the past 5 years in accordance with NFPA 25 section 6-3.6, and

2) The boiler room is not separated from the rest of the building with 2-hour fire rated construction (one door was labeled 1-hour not 1 1/2- hour) and is Type II (000) construction, and no documentation of the suspended ceiling system in the 1973 addition, indicating a 1-hour fire rating was available, the entire building is Type II (000) construction and the entire building is required to be protected by a fire sprinkler system in accordance with NFPA 101 "The Life Safety Code" 2000 edition table 19.1.6.2. Areas not protected with fire sprinkler system include the 1973 addition, the cardiac care area and the kitchen/ dietary rooms.

The Director of Maintenance (MC) verified these findings during the inspection and at the exit conference.

No documentation was available for review to insure that the automatic fire sprinkler system has not been maintained in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 1999 edition section 9.7.5. This deficient practice could allow the system to fail in a fire, which could negatively affect the safety of all patients, staff and visitors of the facility.

Findings include:
Prior to the facility tour on February 7, 2013, at approximately 2:00 pm, no documentation was available for review of the automatic fire sprinkler system testing for the Deer River Meridian Medical Clinic Building.

The Director of Maintenance (MC) verified this finding during the inspection and at the exit conference.

Observations revealed that some electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. This deficiency could negatively effect the any staff and visitors in this area of the facility.

Findings include:
During the facility tour on February 7, 2013, between 10:00 am and 1:30 pm, observations by surveyor 03006, revealed that:

1) An electrical extension cord has been run through the door way into the corridor from the basement level training room, and

2) Power taps have been plugged into another power tap and then into an extension cord in the basement training room.

The Director of Maintenance (MC) verified these findings during the inspection and at the exit conference.