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Based on observation and interview the facility failed to maintain stairways such that they provide a continuous path of escape and provide protection from smoke and fire from other parts of the building. This practice affected all residents, staff, and visitors in 1 of 7 zones in the facility. Census was 14.

Findings are:

Observation on 06-19-12 at 09:45 A.M., revealed that the freight room single door and the wood double doors by the freight room which create a stair exit path do not latch tightly in their frames. This observation was confirmed by Maintenance " A " at the time of observation.

Based on observation and interview, this facility failed to maintain a required exit stairwell, free of the storage of combustibles .This deficient practice affected residents, staff and visitors in 1 of 7 zones. Census was 14.

Findings are:

Observations on 06-19-12 revealed the storage of old wooden doors under the stairs in the east stairway. Interview at the time of observations with Maintenance " A " confirmed that items were being stored in stair well.

NFPA Standard:
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. 2000 NFPA 101, 7.2.2.5.3

Based on Documentation review and Interview, the facility failed to conduct quarterly fire drills on each shift. Not conducting required fire drills puts all patients, staff and visitors at risk should a fire develop. Census was 14.

Findings are:

Documentation review on 06-19-12 at 14:20 P.M., revealed that two of the three shifts had not had the required fire drills. 11-7 shift had only two drills and 3-11 shift had only one drill each in the last 12 months. Interview with Maintenance " A " on 06-19-12 at 14:25 P.M., confirmed the lack of required drills.

Based on Documentation and Interview, the facility failed to provide the required Fire alarm notification within the facility. This places patients, staff and visitors in 1 of 7 zones at risk should a fire develop. Census was 14.

Findings are:

Documentation review on 06-19-12 at 09:47 A.M., revealed that the Clean-Agent extinguishing system alarm in the Network room was not tied to the facility fire alarm system. Interview with Maintenance " A " confirmed the finding at the time of review.

NFPA 101, 19.3.4.2 Initiation of the required fire alarm system shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system water flow alarms, detection devices, or detection systems.

Based on Observation and interview with facility staff, the facility failed to provide a complete fire sprinkler system. Failure to provide a complete system would allow for a fire to develop in the non-sprinklered area and build to the point that the existing fire sprinkler system could not control the fire. This would put patients, staff and visitors in 2 of 7 zones in the existing facility at risk. Census was 14.

Findings are:

1. Observation on 06-19-12 between 10:30 A.M. and 12:15 P.M., revealed that the old patient room/nurses station zone was void the required full fire sprinkler protection. Most of the zone has the sprinklers installed but have not been connected to the system and some rooms in the zone are void any sprinkler heads. Interview with Maintenance " A " during exit interview confirmed that the system was incomplete and advised that the facility was having a hard time keeping the contractor on the job.
2. Observation on 06-19-12 at 11:15 A.M., revealed that the X-Ray CT file room needs additional heads for proper coverage. Interview with Maintenance " A " at the time of observation confirmed the lack of proper coverage due to a wall being moved over to make room for files.

Based on documentation review and interview, the facility failed to maintain the automatic sprinkler system to assure reliable operating condition. The deficient practice could affect all 14 residents, visitors and staff should a fire develop. Census was 14.

Findings are:

Documentation review on 06-19-12 at 10:10 a.m. revealed that the sprinkler System and Fire Pump for the New Addition had not had the required periodic testing performed since the acceptance test. Deficiency was confirmed by maintenance staff at the time of observation.

Based on observation and staff interview, the facility failed to continuously maintain means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This practice affected all residents, visitors and staff in 1 0f 7 zones. Census was 14.

Findings are:

Observations on 06-19-12 at 11:10 A.M., revealed that fire sprinkler pipes and fittings were being stored in the old east patient corridor. This deficiency could the residents staff and Visitors in 1 of 7 Zones if evacuation were necessary. Interview with Maintenance " A " at the time of observation confirmed the items left unattended in the exit corridors.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on Documentation and Interview, the facility failed to provide testing of all extinguishing systems in the facility. This places patients, staff and visitors in 1 of 7 zones at risk should a fire develop. Census was 14.

Findings are:

Documentation review on 06-19-12 at 09:47 A.M., revealed that the Clean-Agent extinguishing system in the Network room had not been inspected within the last 12 months. Interview with Maintenance " A " at the time of review confirmed the lack of inspection.
NFPA 2001, 4-1.1
At least annually, all systems shall be thoroughly inspected and tested for proper operation by competent personnel. Discharge tests are not required.

Based on observation and interview, the facility failed to provide proper electrical wiring throughout the facility. This places all residents, staff and visitors in 1 of 7 zones at risk of shock or fire . Census was 14.

Findings are.

During the survey on 06-19-12 at 11:40 am, it was observed that there was an electrical cord for electronic equipment running through a doorway at the old nurses station and plugged into an outlet in the next room. This practice puts all residents, visitors and staff in 1 of 7 zones at danger of electrical shock or fire. Interview with Maintenance " A " at the time of observance confirmed the cord through a doorway.

Based on observation and interview the facility failed to maintain stairways such that they provide a continuous path of escape and provide protection from smoke and fire from other parts of the building. This practice affected all residents, staff, and visitors in 1 of 7 zones in the facility. Census was 14.

Findings are:

Observation on 06-19-12 at 09:45 A.M., revealed that the freight room single door and the wood double doors by the freight room which create a stair exit path do not latch tightly in their frames. This observation was confirmed by Maintenance " A " at the time of observation.

Based on observation and interview, this facility failed to maintain a required exit stairwell, free of the storage of combustibles .This deficient practice affected residents, staff and visitors in 1 of 7 zones. Census was 14.

Findings are:

Observations on 06-19-12 revealed the storage of old wooden doors under the stairs in the east stairway. Interview at the time of observations with Maintenance " A " confirmed that items were being stored in stair well.

NFPA Standard:
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. 2000 NFPA 101, 7.2.2.5.3

Based on Documentation review and Interview, the facility failed to conduct quarterly fire drills on each shift. Not conducting required fire drills puts all patients, staff and visitors at risk should a fire develop. Census was 14.

Findings are:

Documentation review on 06-19-12 at 14:20 P.M., revealed that two of the three shifts had not had the required fire drills. 11-7 shift had only two drills and 3-11 shift had only one drill each in the last 12 months. Interview with Maintenance " A " on 06-19-12 at 14:25 P.M., confirmed the lack of required drills.

Based on Documentation and Interview, the facility failed to provide the required Fire alarm notification within the facility. This places patients, staff and visitors in 1 of 7 zones at risk should a fire develop. Census was 14.

Findings are:

Documentation review on 06-19-12 at 09:47 A.M., revealed that the Clean-Agent extinguishing system alarm in the Network room was not tied to the facility fire alarm system. Interview with Maintenance " A " confirmed the finding at the time of review.

NFPA 101, 19.3.4.2 Initiation of the required fire alarm system shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system water flow alarms, detection devices, or detection systems.

Based on Observation and interview with facility staff, the facility failed to provide a complete fire sprinkler system. Failure to provide a complete system would allow for a fire to develop in the non-sprinklered area and build to the point that the existing fire sprinkler system could not control the fire. This would put patients, staff and visitors in 2 of 7 zones in the existing facility at risk. Census was 14.

Findings are:

1. Observation on 06-19-12 between 10:30 A.M. and 12:15 P.M., revealed that the old patient room/nurses station zone was void the required full fire sprinkler protection. Most of the zone has the sprinklers installed but have not been connected to the system and some rooms in the zone are void any sprinkler heads. Interview with Maintenance " A " during exit interview confirmed that the system was incomplete and advised that the facility was having a hard time keeping the contractor on the job.
2. Observation on 06-19-12 at 11:15 A.M., revealed that the X-Ray CT file room needs additional heads for proper coverage. Interview with Maintenance " A " at the time of observation confirmed the lack of proper coverage due to a wall being moved over to make room for files.

Based on documentation review and interview, the facility failed to maintain the automatic sprinkler system to assure reliable operating condition. The deficient practice could affect all 14 residents, visitors and staff should a fire develop. Census was 14.

Findings are:

Documentation review on 06-19-12 at 10:10 a.m. revealed that the sprinkler System and Fire Pump for the New Addition had not had the required periodic testing performed since the acceptance test. Deficiency was confirmed by maintenance staff at the time of observation.

Based on observation and staff interview, the facility failed to continuously maintain means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This practice affected all residents, visitors and staff in 1 0f 7 zones. Census was 14.

Findings are:

Observations on 06-19-12 at 11:10 A.M., revealed that fire sprinkler pipes and fittings were being stored in the old east patient corridor. This deficiency could the residents staff and Visitors in 1 of 7 Zones if evacuation were necessary. Interview with Maintenance " A " at the time of observation confirmed the items left unattended in the exit corridors.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on Documentation and Interview, the facility failed to provide testing of all extinguishing systems in the facility. This places patients, staff and visitors in 1 of 7 zones at risk should a fire develop. Census was 14.

Findings are:

Documentation review on 06-19-12 at 09:47 A.M., revealed that the Clean-Agent extinguishing system in the Network room had not been inspected within the last 12 months. Interview with Maintenance " A " at the time of review confirmed the lack of inspection.
NFPA 2001, 4-1.1
At least annually, all systems shall be thoroughly inspected and tested for proper operation by competent personnel. Discharge tests are not required.

Based on observation and interview, the facility failed to provide proper electrical wiring throughout the facility. This places all residents, staff and visitors in 1 of 7 zones at risk of shock or fire . Census was 14.

Findings are.

During the survey on 06-19-12 at 11:40 am, it was observed that there was an electrical cord for electronic equipment running through a doorway at the old nurses station and plugged into an outlet in the next room. This practice puts all residents, visitors and staff in 1 of 7 zones at danger of electrical shock or fire. Interview with Maintenance " A " at the time of observance confirmed the cord through a doorway.