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Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with the National Fire Protection Association (NFPA) Standard 101 (19.3.2.1), The Life Safety Code, 2000 edition. This deficient practice affects 10 staff and visitors in the affected zone. This facility has a capacity of 25 and a census of 8.

Findings include:

Observation and interview on 04/22/15 at 10:42 a.m., revealed that the PT Mechanical/Furnace Room door did not contain a self-closure. The Maintenance Director verified this observation at the time of the survey process.

Based on observation, record review, and interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code. This deficient practice affects all occupants in the facility. This facility has a capacity of 25 and a census of 8.

Findings include:

1. Record review and interview on 04/22/15 at 9:00 a.m., revealed the facility had no documentation for the required semi-annual inspection of the fire alarm system for 2014.

2. Observation and testing of the fire alarm system on 04/22/15 at 11:25 a.m., revealed the visible fire alarm notification strobes on the First Floor were not operating in synchronization.

3. Observation and testing of the fire alarm system on 04/22/15 11:25 a.m., revealed the visible fire alarm notification strobes on the Second Floor were not operating in synchronization. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) Standard 72 (A.5.7.4.1), National Fire Alarm Code, 2007 Edition, which requires that smoke detectors not be located in a direct airflow or closer than three feet from an air supply diffuser or return air opening. This deficient practice affects all occupants in the facility, as smoke detectors located within three feet of a direct air flow, air supply diffuser, or air return opening can impede the operation of the detector. This facility has a capacity of 25 and a census of 8.

Findings include:

1. Observation and interview on 04/22/15 at 9:29 a.m., revealed the two smoke detectors in the First Floor Large Conference Room were located within three feet of air return openings.

2. Observation and interview on 04/22/15 at 10:16 a.m., revealed the smoke detector in Room #ML 221 was located within three feet of the air return opening.

3. Observation and interview on 04/22/15 at 10:52 a.m., revealed the smoke detector in Room #UL 303 was located within three feet of the ceiling fan.

4. Observation and interview on 04/22/15 at 10:59 a.m., revealed the smoke detector in Room #307 was located within three feet of the air return opening.

5. Observation and interview on 04/22/15 at 11:05 a.m., revealed the smoke detector in Room #314 was located within three feet of an air supply diffuser. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 2008 edition. This deficient practice affects all occupants in the facility. This facility has a capacity of 25 and a census of 8.

Findings include:

Observation and interview on 04/22/15 at 11:00 a.m., revealed the Third Floor Linen Closet contained a sprinkler head with paint on the diffuser and arms. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice affects approximately three staff in the affected zones. This facility has a capacity of 25 and a census of 8.

Findings include:

1. Observation and interview on 04/22/15 at 9:41 a.m., revealed that a surge protector was being used to supply power to a fan and a refrigerator in the First Floor Doctor's Lounge.

2. Observation and interview on 04/22/15 at 9:44 a.m., revealed a gray extension cord was being used to supply power to the surge protector supplying power to the computer in the Pharmacy. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with the National Fire Protection Association (NFPA) Standard 101 (19.3.2.1), The Life Safety Code, 2000 edition. This deficient practice affects 10 staff and visitors in the affected zone. This facility has a capacity of 25 and a census of 8.

Findings include:

Observation and interview on 04/22/15 at 10:42 a.m., revealed that the PT Mechanical/Furnace Room door did not contain a self-closure. The Maintenance Director verified this observation at the time of the survey process.

Based on observation, record review, and interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code. This deficient practice affects all occupants in the facility. This facility has a capacity of 25 and a census of 8.

Findings include:

1. Record review and interview on 04/22/15 at 9:00 a.m., revealed the facility had no documentation for the required semi-annual inspection of the fire alarm system for 2014.

2. Observation and testing of the fire alarm system on 04/22/15 at 11:25 a.m., revealed the visible fire alarm notification strobes on the First Floor were not operating in synchronization.

3. Observation and testing of the fire alarm system on 04/22/15 11:25 a.m., revealed the visible fire alarm notification strobes on the Second Floor were not operating in synchronization. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) Standard 72 (A.5.7.4.1), National Fire Alarm Code, 2007 Edition, which requires that smoke detectors not be located in a direct airflow or closer than three feet from an air supply diffuser or return air opening. This deficient practice affects all occupants in the facility, as smoke detectors located within three feet of a direct air flow, air supply diffuser, or air return opening can impede the operation of the detector. This facility has a capacity of 25 and a census of 8.

Findings include:

1. Observation and interview on 04/22/15 at 9:29 a.m., revealed the two smoke detectors in the First Floor Large Conference Room were located within three feet of air return openings.

2. Observation and interview on 04/22/15 at 10:16 a.m., revealed the smoke detector in Room #ML 221 was located within three feet of the air return opening.

3. Observation and interview on 04/22/15 at 10:52 a.m., revealed the smoke detector in Room #UL 303 was located within three feet of the ceiling fan.

4. Observation and interview on 04/22/15 at 10:59 a.m., revealed the smoke detector in Room #307 was located within three feet of the air return opening.

5. Observation and interview on 04/22/15 at 11:05 a.m., revealed the smoke detector in Room #314 was located within three feet of an air supply diffuser. The Maintenance Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 2008 edition. This deficient practice affects all occupants in the facility. This facility has a capacity of 25 and a census of 8.

Findings include:

Observation and interview on 04/22/15 at 11:00 a.m., revealed the Third Floor Linen Closet contained a sprinkler head with paint on the diffuser and arms. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice affects approximately three staff in the affected zones. This facility has a capacity of 25 and a census of 8.

Findings include:

1. Observation and interview on 04/22/15 at 9:41 a.m., revealed that a surge protector was being used to supply power to a fan and a refrigerator in the First Floor Doctor's Lounge.

2. Observation and interview on 04/22/15 at 9:44 a.m., revealed a gray extension cord was being used to supply power to the surge protector supplying power to the computer in the Pharmacy. The Maintenance Director verified these observations at the time of the survey process.