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Based on observations and staff interview, it was determined the facility was a one-story building and consisted of protected fire rated construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with fire rated materials. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observations and staff interview on 7/9/13, revealed the following deficiencies:

1. There was a penetration, (approximately 1/4 inch), around a conduit extending through the ceiling of the Kitchen Mop Closet.
2. There was a penetration, (approximately 1/2 inch), around a conduit extending through the ceiling of the Kitchen Mop Closet.
3. There was a penetration, (approximately 1/2 inch), around a conduit extending through the ceiling of the Kitchen Mop Closet.
4. There was a penetration, (approximately 1/4 inch), around a conduit extending through the ceiling of the Kitchen Mop Closet.
5. There were 7 open pipes, (all approximately 1 inch), extending through the ceiling of the Surgery Janitor Closet.
6. There was a penetration, (approximately 1/4 inch), around communications cables extending through the ceiling of the Radiology Electrical Room.
7. There was a penetration, (approximately 1/4 inch), around a conduit extending through the wall of the Radiology Electrical Room.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to separate the corridors from other areas by partitions complying with 19.3.6.2 through 19.3.6.5 of the 2000 Life Safety Code. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. This facility has a capacity 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 7/9/13, revealed the following deficiencies:

1. There was a hole, (approximately 1/4 inch), in ceiling of the OB Corridor by LDR Suite 1.
2. There was a penetration, (approximately 1/4 inch), around a communications cable extending through the ceiling of the OB Corridor by LDR Suite 1.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility is not ensuring that doors to areas other than hazardous rooms are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 7/9/13, revealed that the door to the Clinic Corridor did not close and latch properly. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to ensure that all stairwells and vertical openings between floors consist of construction with a one hour fire resistance rating. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 7/9/13, revealed a penetration, (approximately 1/4 inch), around a sprinkler pipe extending through the 1st Floor Center Stairwell Wall above the fire door. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain two smoke barrier in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observations and staff interview on 7/9/13, revealed the following deficiencies:

1. There was a penetration, (approximately 3/16 inch), around communications cables extending through the B Wing Smoke Barrier Wall.
2. There was a penetration, (approximately 1/4 inch), around communications cables extending through the A Wing Smoke Barrier Wall.
3. There was a penetration, (approximately 2 inches), around communications cables extending through the A Wing Smoke Barrier Wall.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, 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 protected combustible construction and unprotected noncombustible construction equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observations and staff interview on 7/9/13, revealed the following deficiencies:

1. The door to the Oxygen Storage Room by the Boiler Room did not close and latch properly.
2. The door to the Boiler Room did not close and latch properly.
3. There was a hole, (approximately 2 inches), in the wall of the Dialysis Center Water Treatment Room.
4. There was a penetration, (approximately 1/4 inch), around a sprinkler test pipe extending through the ceiling of the Med Surg Soiled Utility Room.
The door to the Surgery Clean Work Room did not close and latch properly.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to properly protect 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. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 7/9/13, revealed that the circuit breaker supplying power to the fire alarm system in the Wellness Center is not mechanically protected. Maintenance Staff A verified observations during the survey process.

Based on record review, observations and staff interview, 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 a capacity of 25 with a census of 9 residents.

Findings include:

Record review, observations and staff interview on 7/9/13, revealed the following deficiencies:

1. There was no available documentation of quarterly sprinkler system inspection for the 1st and 2nd Quarters of 2012. The only available documentation of sprinkler system inspections was noted on the dates of 9/11/12 and 11/26/12.
2. There was an escutcheon around a sprinkler head that was not flush with the ceiling in the Kitchen Storage Room.
3. There was a missing escutcheon for a sprinkler head located in the corridor by the Kitchen Mop Closet.
4. There was a missing escutcheon for a sprinkler head located in the A-Wing Corridor by the oxygen shut-off valves.
5. There was an escutcheon around a sprinkler head that was not flush with the ceiling in the Nursery.
6. There was an escutcheon around a sprinkler head that was not flush with the ceiling in the OB Corridor by LDR Suite 1.

Maintenance Staff A verified record review and observations during the survey process.



Maintenance Staff A verified observations during the survey process.

Based on record review staff interview, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Record review and staff interview on 7/9/13, revealed no documentation of monthly inspections of the Kitchen hood and duct extinguishment system. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Record review and staff interview on 7/9/13, revealed no documentation of amperage readings or exhaust temperature when the generator is tested under load to verify that the generator is operating at 30% of the nameplate value. Maintenance Staff A verified record review during the survey process.

Based on observations and staff interview, it was determined the facility was a one-story building and consisted of protected fire rated construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with fire rated materials. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observations and staff interview on 7/9/13, revealed the following deficiencies:

1. There was a penetration, (approximately 1/4 inch), around a conduit extending through the ceiling of the Kitchen Mop Closet.
2. There was a penetration, (approximately 1/2 inch), around a conduit extending through the ceiling of the Kitchen Mop Closet.
3. There was a penetration, (approximately 1/2 inch), around a conduit extending through the ceiling of the Kitchen Mop Closet.
4. There was a penetration, (approximately 1/4 inch), around a conduit extending through the ceiling of the Kitchen Mop Closet.
5. There were 7 open pipes, (all approximately 1 inch), extending through the ceiling of the Surgery Janitor Closet.
6. There was a penetration, (approximately 1/4 inch), around communications cables extending through the ceiling of the Radiology Electrical Room.
7. There was a penetration, (approximately 1/4 inch), around a conduit extending through the wall of the Radiology Electrical Room.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to separate the corridors from other areas by partitions complying with 19.3.6.2 through 19.3.6.5 of the 2000 Life Safety Code. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. This facility has a capacity 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 7/9/13, revealed the following deficiencies:

1. There was a hole, (approximately 1/4 inch), in ceiling of the OB Corridor by LDR Suite 1.
2. There was a penetration, (approximately 1/4 inch), around a communications cable extending through the ceiling of the OB Corridor by LDR Suite 1.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility is not ensuring that doors to areas other than hazardous rooms are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 7/9/13, revealed that the door to the Clinic Corridor did not close and latch properly. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to ensure that all stairwells and vertical openings between floors consist of construction with a one hour fire resistance rating. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 7/9/13, revealed a penetration, (approximately 1/4 inch), around a sprinkler pipe extending through the 1st Floor Center Stairwell Wall above the fire door. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain two smoke barrier in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observations and staff interview on 7/9/13, revealed the following deficiencies:

1. There was a penetration, (approximately 3/16 inch), around communications cables extending through the B Wing Smoke Barrier Wall.
2. There was a penetration, (approximately 1/4 inch), around communications cables extending through the A Wing Smoke Barrier Wall.
3. There was a penetration, (approximately 2 inches), around communications cables extending through the A Wing Smoke Barrier Wall.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, 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 protected combustible construction and unprotected noncombustible construction equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observations and staff interview on 7/9/13, revealed the following deficiencies:

1. The door to the Oxygen Storage Room by the Boiler Room did not close and latch properly.
2. The door to the Boiler Room did not close and latch properly.
3. There was a hole, (approximately 2 inches), in the wall of the Dialysis Center Water Treatment Room.
4. There was a penetration, (approximately 1/4 inch), around a sprinkler test pipe extending through the ceiling of the Med Surg Soiled Utility Room.
The door to the Surgery Clean Work Room did not close and latch properly.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility failed to properly protect 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. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Observation and staff interview on 7/9/13, revealed that the circuit breaker supplying power to the fire alarm system in the Wellness Center is not mechanically protected. Maintenance Staff A verified observations during the survey process.

Based on record review, observations and staff interview, 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 a capacity of 25 with a census of 9 residents.

Findings include:

Record review, observations and staff interview on 7/9/13, revealed the following deficiencies:

1. There was no available documentation of quarterly sprinkler system inspection for the 1st and 2nd Quarters of 2012. The only available documentation of sprinkler system inspections was noted on the dates of 9/11/12 and 11/26/12.
2. There was an escutcheon around a sprinkler head that was not flush with the ceiling in the Kitchen Storage Room.
3. There was a missing escutcheon for a sprinkler head located in the corridor by the Kitchen Mop Closet.
4. There was a missing escutcheon for a sprinkler head located in the A-Wing Corridor by the oxygen shut-off valves.
5. There was an escutcheon around a sprinkler head that was not flush with the ceiling in the Nursery.
6. There was an escutcheon around a sprinkler head that was not flush with the ceiling in the OB Corridor by LDR Suite 1.

Maintenance Staff A verified record review and observations during the survey process.



Maintenance Staff A verified observations during the survey process.

Based on record review staff interview, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Record review and staff interview on 7/9/13, revealed no documentation of monthly inspections of the Kitchen hood and duct extinguishment system. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has a capacity of 25 with a census of 9 patients.

Findings include:

Record review and staff interview on 7/9/13, revealed no documentation of amperage readings or exhaust temperature when the generator is tested under load to verify that the generator is operating at 30% of the nameplate value. Maintenance Staff A verified record review during the survey process.