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Based on observation and staff interview, the facility failed to provide a construction type with a complete one-hour fire rated UL rated ceiling tile assembly or a continuous membrane ceiling assembly required by the protected non-combustible construction of the building. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 25 and had a census of 5 residents.
Findings include:

1. Observations and staff interviews on 08/03/11, revealed a missing ceiling tile in the corridor located by the door to the Dietary Managers Office. Maintenance Staff A verified and observed this observation. They advised the tile was missing because work on a water leak was being done throughout the building.

2. Observations and staff interview on 08/03/11, revealed a missing ceiling located in the Control Rooms Equipment Room in Radiology. Maintenance Staff A verified and observed this observation. They advised the tile was missing because work on a water leak was being done throughout the building.

3. Observations and staff interview on 08/03/11, revealed a missing ceiling tiles located throughout the Nurses Station in the Medical Unit. Maintenance Staff A verified and observed this observation. They advised the tile was missing because work on a water leak was being done throughout the building.

4. Observations and staff interviews on 08/03/11, revealed a hole (approximately 2 inches by 3 inches) located behind the Omni Cell at the Emergency Room Nurses Station and a hole (approximately 3 inches x 4 inches) located by the refrigerator at the same nurses station. Maintenance Staff A observed and verified this observation.

Based on observation and interviews, the facility failed to provide smoke doors that closed with the fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72. This deficient practice affects all occupants of the building. The facility has a capacity of 25 and at the time of the survey the census was 5 patients.

Findings include:

1) Observations and staff interviews on 08/03/11, revealed the smoke doors located in the corridor between Dietary and Surgery failed to close when the fire alarm was activated. The doors are held open by a magnetic device and should release when the fire alarm is activated. Maintenance Staff A verified and observed this observation.

2) Observations and staff interviews on 08/03/11, revealed the smoke doors located in the corridor between the Emergency Room and Radiology failed to close when the fire alarm was activated. The doors are held open by a magnetic device and should release when the fire alarm is activated. Maintenance Staff A verified and observed this observation

Based on observations and interviews, 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 affects occupants in 1 of 7 smoke zones as the doors would not prevent the spread of fire and smoke. The facility has a capacity for25 and at the time of the survey the census was 5 patients

Findings include:

1) Observations and staff interviews on 08/03/11, revealed the door to the Lab Storage Room did not have the requried closing hardware attached.

2) Obseravtions and staff interviews on 08/03/11, revealed the door to the Clean Storage Area in the Surgery Area did not have the required closing hardware attached.

Maintenance Staff A observed and verified these observations during the survey.

Based on observations and staff interview, the facility failed to properly install and maintain the delayed egress locks in accordance with National Fire Protection Association ( NFPA) Standard 101, Life Safety Code, 2000 edition, 7.2.1.6. Delayed egress specialized locking system installations in existing buildings shall be submitted to the Fire Prevention Bureau for approval. This deficient practice affects occupants in two of seven zones. The facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

1. Observation on08/03/11, revealed the irreversible process for the magnetic lock to release the corridor doors to the Maintenance area exit door did not activate to release the door when pressure was applied. However, the magnetic lock did release upon activation of the fire alarm system.

2. Observation on08/03/11, revealed the irreversible process for the magnetic lock to release the corridor doors to the OB Ward exit door did not activate to release the door when pressure was applied. However, the magnetic lock did release upon activation of the fire alarm system.

3. Observation on08/03/11, revealed the irreversible process for the magnetic lock to release the corridor doors located by the Foundation Office door did not activate to release the door when pressure was applied. However, the magnetic lock did release upon activation of the fire alarm system.

Maintenance Staff A verified and observed this observation during this survey.

Based on observations and staff interview, the facility is not providing unobstructed corridors that provides a clear path of egress for 1 of 7 smoke zones. This facility has a capacity of 25 with a census of 5.

Findings include:

Observations and interviews on 08/03/11, revealed the facility was using the corridor for wheel chair storage. This practice blocks the path of egress for the persons using the Emergency Room Corridor as an exit. Maintenance Staff A observed and verified this observation during the survey. Maintenance Staff A advised they have other options as to where to store the chairs.

Based on observation and staff 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 not providing the required documentation of installation and testing of the fire alarm system.
Findings include:
Observations and staff interview on 08/03/11, revealed the facility was unable to produce the documentation of proper installation and maintenance of the fire alarm system. Maintenance Staff A observed and verified this observation.

Based on observation the facility failed to provide a properly protect and label the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 5 patients.

Findings include:

Observations on 08/03/11, revealed the circuit breaker for the fire alarm's primary power supply was located in the electrical panel CC1 Breakers number 12 and 16. The circuit breaker was not mechanically protected and was not properly labeled. Also the location on the circuit disconnecting was not labeled on the fire alarm control panel.

Based on observations and interviews, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, 7-4.1, by ensuring smoke detectors are maintained in normal operating condition. The campus has 25 certified beds and at the time of the revisit the census was 5.

Findings include:


Observations and staff interviews on 08/03/11, revealed a smoke detector that was hanging by wires in the Enviormental Service Room. Maintenance Staff A observed and verified this observation. They advised maintenance on the alarm was being conducted at the time of the survey.

Based on observations and staff interviews, the facility failed to ensure that automatic sprinkler systems are continuously maintained in reliable operating conditioned are inspected and tested periodically. LCD 18.7.6, 19.7.6, 4.6.12, NFPA13, NFPA25,9.7.5

Findings include:

Observations and staff interviews on 08/03/11, revealed the facility had no documentation available at the time of this survey that states the sprinkler was installed and maintained properly. Maintenance Staff A observed and verified this observation.

Based on observations and staff interview, 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. Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. The facility has a capacity of 25 and at the time of the survey process the census was 5 patients.

Findings include:

Observations on 08/03/11, revealed the K type fire extinguisher was sitting on the floor and access to it was obstructed by kitchen carts. Maintenance Staff A observed and verified this observation and stated they were attempting to relocated the extinguisher..

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. These deficiencies affects 2 rooms which staff uses only. This facility has a capacity of 25 and a census of 5 patients.

Findings include:

1. Observations and staff interviews on 08/03/11, revealed the required 36 inch work space was not being provided for the electric panel in Room B142. Maintenance Staff A verified these observations during the survey process.

2. Observations and staff interviews on 08/03/11, revealed a junction box cover that was missing. This junction box was located in the Mechanical Room on the ceiling by the sprinkler riser. Maintenance Staff A verified these observations during the survey process.