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Based on observation and interview this facility is not assuring that two smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects all occupants of the building, including staff, visitors and residents in four of nineteen smoke zones. This facility has a capacity of 25 with a census of 12 residents.

Findings include:

1. Observation and interview on 9-29-15 at approximately 12:06 p.m., the 1st Floor Service Corridor over the smoke doors above the ceiling tiles contained 2 (one inch) holes were old conduits were removed.

2. Observation and interview on 9-29-15 at approximately 12:20 p.m., over the smoke doors next to the 1st Floor West Elevator above the ceiling tiles there were 2 (one inch) conduits with 1/2 inch gaps around the conduits.

Maintenance Staff (A) confirmed these observations and repaired deficiencies at the time of the survey.

Based on observation and interview the facility failed to maintain the exit discharge lighting so that the path of egress would not be in darkness. This deficient practice affects all occupants and patients of the Boone County Family Medicine Clinic. This facility has a capacity of 25 and a census of 12 residents.
Findings include:
1. Observation and interview on 9-29-15 at 1:30 p.m., the battery operated emergency light on the west basement wall failed to operate when tested.
2. Observation and interview on 9-29-15 at 1:35 p.m., the battery operated emergency light #12 in the Northeast Hall failed to operate when tested.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the Boone County Family Medicine Clinic, including staff, visitors and residents. This facility has a capacity of 25 with a census of 12.

Findings include:

Observation and interview on 9-29-15, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the Basement electrical panel 4 breaker #4 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to inspect the Hood Suppression system every 6 months as required. This could affect the Kitchen smoke compartment and all occupants in one of nineteen smoke compartments in the building . This facility has a capacity of 25 and a census of 12 residents.

Findings include:

During the record review of the facility ' s fire safety components on 9-29-15, revealed the hood suppression system was inspected on 6-5-14 by Simplex. The hood suppression system was inspected by CEC on 8-10-15. The facility was unable to provide documentation of an inspection for the system six months after the June 2014 inspection. The inspection report by CEC was a pass-fail report without the specific inspection requirements.

Maintenance Staff (A) confirmed this record review.

Based on observation and interview, 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, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 12 at the time of the survey.

Findings Include:

1. Observation and interview on 9-29-15 at approximately 11:32 a.m., revealed the facility failed to prohibit the use of an extension cord. On the above date an extension cord was observed on the south wall of the Gift Shop used for a lamp.

2. Observations and interview on 9-29-15 at 11:36 a.m., revealed the facility failed to maintain the electrical system in the Surgery corridor panel EC1A. Breaker #7 was on and charged and labeled as a spare. Breaker #15 was not labeled and was in the on position and charged.

3. Observations and interview on 9-29-15 at 11:36 a.m., revealed the facility failed to maintain the electrical system in the Surgery corridor panel L1C. Breakers #12 & #16 were on and charged and not labeled.

Maintenance Staff (A) verified these observations.

Based on observation and interview this facility is not assuring that two smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects all occupants of the building, including staff, visitors and residents in four of nineteen smoke zones. This facility has a capacity of 25 with a census of 12 residents.

Findings include:

1. Observation and interview on 9-29-15 at approximately 12:06 p.m., the 1st Floor Service Corridor over the smoke doors above the ceiling tiles contained 2 (one inch) holes were old conduits were removed.

2. Observation and interview on 9-29-15 at approximately 12:20 p.m., over the smoke doors next to the 1st Floor West Elevator above the ceiling tiles there were 2 (one inch) conduits with 1/2 inch gaps around the conduits.

Maintenance Staff (A) confirmed these observations and repaired deficiencies at the time of the survey.

Based on observation and interview the facility failed to maintain the exit discharge lighting so that the path of egress would not be in darkness. This deficient practice affects all occupants and patients of the Boone County Family Medicine Clinic. This facility has a capacity of 25 and a census of 12 residents.
Findings include:
1. Observation and interview on 9-29-15 at 1:30 p.m., the battery operated emergency light on the west basement wall failed to operate when tested.
2. Observation and interview on 9-29-15 at 1:35 p.m., the battery operated emergency light #12 in the Northeast Hall failed to operate when tested.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the Boone County Family Medicine Clinic, including staff, visitors and residents. This facility has a capacity of 25 with a census of 12.

Findings include:

Observation and interview on 9-29-15, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the Basement electrical panel 4 breaker #4 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to inspect the Hood Suppression system every 6 months as required. This could affect the Kitchen smoke compartment and all occupants in one of nineteen smoke compartments in the building . This facility has a capacity of 25 and a census of 12 residents.

Findings include:

During the record review of the facility ' s fire safety components on 9-29-15, revealed the hood suppression system was inspected on 6-5-14 by Simplex. The hood suppression system was inspected by CEC on 8-10-15. The facility was unable to provide documentation of an inspection for the system six months after the June 2014 inspection. The inspection report by CEC was a pass-fail report without the specific inspection requirements.

Maintenance Staff (A) confirmed this record review.

Based on observation and interview, 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, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 12 at the time of the survey.

Findings Include:

1. Observation and interview on 9-29-15 at approximately 11:32 a.m., revealed the facility failed to prohibit the use of an extension cord. On the above date an extension cord was observed on the south wall of the Gift Shop used for a lamp.

2. Observations and interview on 9-29-15 at 11:36 a.m., revealed the facility failed to maintain the electrical system in the Surgery corridor panel EC1A. Breaker #7 was on and charged and labeled as a spare. Breaker #15 was not labeled and was in the on position and charged.

3. Observations and interview on 9-29-15 at 11:36 a.m., revealed the facility failed to maintain the electrical system in the Surgery corridor panel L1C. Breakers #12 & #16 were on and charged and not labeled.

Maintenance Staff (A) verified these observations.