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Based on observation and staff interview, the facility failed to provide separation of rated two story exit stair areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel between exit corridor(s) and the rated exit stair(s), potentially endangering safe exit passage and potentially affecting 19 patients on both floor levels in 2 of 2 smoke zones. This facility has a capacity of 19 with a census of 3.

FINDINGS INCLUDE:

During the tour on 03/21/2013 between the hours of 10:00 AM and 4:30 PM, observation found on the First Floor in the North Stair above the lay-in ceiling and exit door there is a Sprinkler Pipe/Flexable electrical conduit/low voltage wiring penetration approximately 3 inches in diameter that is not properly and completly fire caulked.

Administrative Staff A and Maintenance Staff A, B and C were present and acknowledged the findings.

NFPA Standard: Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5.6. NFPA 2000 Life Safety Code 101: 19.3.1.1.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and/or fire to travel between the noted hazardous room and adjacent space as noted, potentially affecting 9 patients in 1 of 2 smoke zones. This facility has a capacity of 19 with a census of 3.

FINDINGS INCLUDE:

During the tour on 03/21/2013 between the hours of 10:00 AM and 4:30 PM, observation on the second floor in what is currently being called the Resource Room is actually a Supply Storage Room of over 50 sq ft that has its door being held open by a lockout on the automatic door closer.

Administrative Staff A and Maintenance Staff A, B and C were present and acknowledged the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation and staff interview, the facility failed to assure that sprinklers have proper escutcheons in place and/or are clear of loading with lint/dust build up. The deficient practice fails to ensure the required sprinkler coverage in the event of a fire, potentially affecting 9 patients in 1 of 2 smoke zones. The facility has a capacity of 19 with a census of 3.

FINDINGS INCLUDE:

During the tour on 03/21/2013 between the hours of 10:00 AM and 4:30 PM it is observed that there are missing sprinkler head escutcheons on sprinkler heads in the lay-in ceilings of Patient Room 1 and in the Business Office Rest Room (one sprinkler head in each room).

Administrative Staff A and Maintenance Staff A, B and C were present and acknowledged the findings.

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3

Based on observation and staff interview, the facility failed to maintain electrical wiring systems that meet 1999 NFPA 72 guidelines. This deficient practice could potentially cause injury, an electrical short, electrical failure or fire and potentially affects 19 patients and staff in 2 of 2 smoke zones. The facility has a capacity of 19 with a census of 3.

FINDINGS INCLUDE:

During the tour on 03/21/2013 between the hours of 10:00 AM and 4:30 PM it is observed that:

1) On the Second Floor in the North Stair above the lay-in ceiling and exit door there is an open 110 volt electrical 4x4 J-box serving the lighting system.

2) On the First Floor in the Sterilizer Room there is an Electrical Panel that is being blocked by an autoclave type sterilizer machine.

Administrative Staff A and Maintenance Staff B were present and acknowledged the findings.

NFPA Standard: Extensions shall consist of a continuous unbroken length of assembly, without splices, and without exposed conductors between fittings. Taps shall be permitted where approved fittings and boxes completely cover the tap connections that are used. 1999 NFPA 70, Article 382-56

NFPA Standard: Electrical wiring and equipment shall be in accordance with the 1999 NFPA 70, Article 9.1.2.