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Based on observation and interview, it was determined the facility is a two-story building and consisted of a fire resistive building. The facility failed to assure minimum building construction requirements were maintained. This facility has a capacity of 21 patients and at the time of the survey the census was 10.

Findings include:

Observation and interview on 6/1/11, revealed a hole (approximately 1/2 inch in size) above the door handle of the PT Utility Room. Maintenance Staff A verified this observation.

Based on surveyor observation and interview, the facility is not ensuring that doors to patient rooms, offices and other ancillary areas 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. This facility has a capacity of 21 and a census of 10 .

Findings include:

1. Observation and interview on 6/1/11, revealed the corridor door to the PT Utility Room did not close and latch properly when tested.
2. Observation and interview on 6/1/11, revealed the corridor door to the Maintenance Storage by the clinic office did not close and latch properly when tested. This door also contained a louver at the bottom of the door which would not prevent the spread of smoke into the corridor.
3. Observation and interview on 6/1/11, revealed the door to the Tunnel Entrance by maintenance did not latch properly when tested.

Maintenance Staff A verified these observations.

Based on observations and interview, the facility failed to provide separation of hazardous areas from other compartments. These deficient practice would affect all occupants of the building. The facility has a capacity of 21 and at the time of the survey the census was 10 patients.

Findings include:

1. Observation and interview on 6/1/11, revealed a gap (approximately 3/4 inch in size) around a fiber optic line above the corridor door in the Maintenance Shop.
2. Observation and interview on 6/1/11, revealed the door to the Shred Storage did not latch properly when tested.
3. Observation and interview on 6/1/11, revealed the previous K29 deficiency that was cited on 6/12/06 has not been corrected. Hazardous areas throughout the building that are not sprinklered do not have 45 minute rated doors. These areas include the following: storage rooms over 50 square feet, laundry rooms over 100 square feet, boiler rooms, repair and paint shops, labs, soiled linen rooms and trash collection rooms.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not assuring that the fire alarm system is in accordance with National Fire Protection Association (NFPA) Standard 72. This deficient practice affects all occupants of the building. This facility has 21 certified beds and at the time of the survey the census was 10.

Findings include:

Observations, record review and interview on 6/1/11, revealed the previous K51 deficiency that was cited on 1/9/03 and 6/12/06 has not been corrected. The following areas failed to be protected by the required fire alarm system: Corridors, X-ray Rooms, Housekeeping Rooms, Offices, Storage Closets, Ultra Sound, Linen Closets, Utility Rooms, Basement Electrical Tunnel, Elevator Room, Elevator Shaft, Dietary Kitchen, Conference Room, Sitz Bath, Pharmacy and Stairwells. Corridor smoke detection was not located 30 foot on center throughout the building. Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to 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 21 and a census of 10 patients.

Findings include:

Observations and interview on 6/1/11, revealed the circuit breaker for the fire alarms primary power supply was located in electrical panel located in the Surgery Hallway. The circuit breaker was not mechanically protected. Maintenance Staff A verified this observation.

Based on observations and interview, the facility failed to 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.
Findings include:

Observations and interview on 6/3/11, revealed the circuit breaker for the fire alarms primary power supply was located in the Basement Electrical Panel (#28) for the Physical Therapy Clinic and the Medical Clinic (Suites C & D). The circuit breakers were not mechanically protected and were not properly labeled. Maintenance Staff A verified these observations.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed with direct airflow, nor closer than three feet to air supply or air return. Installation of smoke detectors close to a ceiling fan/air supply/air return can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 21 and a census of 10 .

Findings include:

1. Observations and interview on 6/1/11, revealed the following areas had smoke detectors located within three feet of an air supply, air return or ceiling fan: corridor outside of OB Nurse's Station, Birthing Room 2, Birthing Room Entry, Soiled Utility by birthing rooms, and Procedure Room in the North Clinic.
2. Observation and interview on 6/1/11, revealed a heat detector that was not secured to the ceiling in the Food Storage located within the kitchen.
3. Observation, interview and record review on 6/1/11, revealed the following on the inspection report dated 2/3/11 for the Medical Clinic: "2 heats on east side above nurse's station are t-tapped". There was no documentation to show that this item had been corrected.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25 by storing numerous items on the sprinkler pipes. This deficient could affect all occupants of the building. This facility has a capacity of 21 patients and a census of 10.

Findings include:

Observations on 6/1/11, revealed a numerous items being stored on top of the sprinkler piping in the Maintenance Shop. Maintenance Staff A verified this observation.

Based on record review, interview and observation, 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 and all occupants of the building could be affected by this deficient practice.

Findings include:

1. During record review, interview and observation of the facilities fire safety components on 6/3/11, revealed the absence of documentation to indicate that annual and quarterly inspections of the sprinkler system had been performed. Maintenance Staff A stated that he was not aware that there was a sprinkler system located in the building. The basement portion of the building is sprinklered.
2. During record review and interview on 6/3/11, it was revealed that the facility failed to have a 5 year internal pipe inspection on the sprinkler system.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. The facility has 21 certified beds and at the time of the survey the facility census was 10.

Findings include:

Observations and interview on 6/1/11, revealed the absence of monthly visual inspections on the ansul pull station. Maintenance Staff A verified this observation.

Based on observation and staff interview, the facility failed to provide window hangings that were flame resistant in accordance with provisions of National Fire Protection Association (NFPA) 101, 10.3. This facility has 21 certified beds and at the time of the survey the census was 10.

Findings include:

1. Observation and interview on 6/1/11, revealed the curtains in the Patient Kitchenette was not tagged as being flame retardant.
2. Observation and interview on 6/1/11, revealed the curtains in the Diabetes Education Training Room were not tagged as being flame retardant.
3. Observation and interview on 6/1/11, revealed the curtain on the closet in the Chief Operating Officer's office was not tagged as being flame retardant.
4. Observation and interview on 6/1/11, revealed the blanket on the wall in the Foundation Director's Office was not tagged as being flame retardant.

Maintenance Staff A verified these observations.

Based on observation and interview, 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.

Findings include:

Observation and interview on 6/3/11, revealed a missing junction box cover in the Basement above the door going upstairs to the Clinic. Maintenance Staff A verified this observation.

Based on observations and interview, 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. This facility has a capacity of 21 and a census of 10 patients.

Findings include:

Observations and interview on 6/1/11, revealed an open junction box on the east wall in the Surgical Mechanical Room. Maintenance Staff A verified this observation.

Based on observation and interview, it was determined the facility is a two-story building and consisted of a fire resistive building. The facility failed to assure minimum building construction requirements were maintained. This facility has a capacity of 21 patients and at the time of the survey the census was 10.

Findings include:

Observation and interview on 6/1/11, revealed a hole (approximately 1/2 inch in size) above the door handle of the PT Utility Room. Maintenance Staff A verified this observation.

Based on surveyor observation and interview, the facility is not ensuring that doors to patient rooms, offices and other ancillary areas 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. This facility has a capacity of 21 and a census of 10 .

Findings include:

1. Observation and interview on 6/1/11, revealed the corridor door to the PT Utility Room did not close and latch properly when tested.
2. Observation and interview on 6/1/11, revealed the corridor door to the Maintenance Storage by the clinic office did not close and latch properly when tested. This door also contained a louver at the bottom of the door which would not prevent the spread of smoke into the corridor.
3. Observation and interview on 6/1/11, revealed the door to the Tunnel Entrance by maintenance did not latch properly when tested.

Maintenance Staff A verified these observations.

Based on observations and interview, the facility failed to provide separation of hazardous areas from other compartments. These deficient practice would affect all occupants of the building. The facility has a capacity of 21 and at the time of the survey the census was 10 patients.

Findings include:

1. Observation and interview on 6/1/11, revealed a gap (approximately 3/4 inch in size) around a fiber optic line above the corridor door in the Maintenance Shop.
2. Observation and interview on 6/1/11, revealed the door to the Shred Storage did not latch properly when tested.
3. Observation and interview on 6/1/11, revealed the previous K29 deficiency that was cited on 6/12/06 has not been corrected. Hazardous areas throughout the building that are not sprinklered do not have 45 minute rated doors. These areas include the following: storage rooms over 50 square feet, laundry rooms over 100 square feet, boiler rooms, repair and paint shops, labs, soiled linen rooms and trash collection rooms.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not assuring that the fire alarm system is in accordance with National Fire Protection Association (NFPA) Standard 72. This deficient practice affects all occupants of the building. This facility has 21 certified beds and at the time of the survey the census was 10.

Findings include:

Observations, record review and interview on 6/1/11, revealed the previous K51 deficiency that was cited on 1/9/03 and 6/12/06 has not been corrected. The following areas failed to be protected by the required fire alarm system: Corridors, X-ray Rooms, Housekeeping Rooms, Offices, Storage Closets, Ultra Sound, Linen Closets, Utility Rooms, Basement Electrical Tunnel, Elevator Room, Elevator Shaft, Dietary Kitchen, Conference Room, Sitz Bath, Pharmacy and Stairwells. Corridor smoke detection was not located 30 foot on center throughout the building. Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to 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 21 and a census of 10 patients.

Findings include:

Observations and interview on 6/1/11, revealed the circuit breaker for the fire alarms primary power supply was located in electrical panel located in the Surgery Hallway. The circuit breaker was not mechanically protected. Maintenance Staff A verified this observation.

Based on observations and interview, the facility failed to 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.
Findings include:

Observations and interview on 6/3/11, revealed the circuit breaker for the fire alarms primary power supply was located in the Basement Electrical Panel (#28) for the Physical Therapy Clinic and the Medical Clinic (Suites C & D). The circuit breakers were not mechanically protected and were not properly labeled. Maintenance Staff A verified these observations.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed with direct airflow, nor closer than three feet to air supply or air return. Installation of smoke detectors close to a ceiling fan/air supply/air return can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 21 and a census of 10 .

Findings include:

1. Observations and interview on 6/1/11, revealed the following areas had smoke detectors located within three feet of an air supply, air return or ceiling fan: corridor outside of OB Nurse's Station, Birthing Room 2, Birthing Room Entry, Soiled Utility by birthing rooms, and Procedure Room in the North Clinic.
2. Observation and interview on 6/1/11, revealed a heat detector that was not secured to the ceiling in the Food Storage located within the kitchen.
3. Observation, interview and record review on 6/1/11, revealed the following on the inspection report dated 2/3/11 for the Medical Clinic: "2 heats on east side above nurse's station are t-tapped". There was no documentation to show that this item had been corrected.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25 by storing numerous items on the sprinkler pipes. This deficient could affect all occupants of the building. This facility has a capacity of 21 patients and a census of 10.

Findings include:

Observations on 6/1/11, revealed a numerous items being stored on top of the sprinkler piping in the Maintenance Shop. Maintenance Staff A verified this observation.

Based on record review, interview and observation, 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 and all occupants of the building could be affected by this deficient practice.

Findings include:

1. During record review, interview and observation of the facilities fire safety components on 6/3/11, revealed the absence of documentation to indicate that annual and quarterly inspections of the sprinkler system had been performed. Maintenance Staff A stated that he was not aware that there was a sprinkler system located in the building. The basement portion of the building is sprinklered.
2. During record review and interview on 6/3/11, it was revealed that the facility failed to have a 5 year internal pipe inspection on the sprinkler system.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. The facility has 21 certified beds and at the time of the survey the facility census was 10.

Findings include:

Observations and interview on 6/1/11, revealed the absence of monthly visual inspections on the ansul pull station. Maintenance Staff A verified this observation.

Based on observation and staff interview, the facility failed to provide window hangings that were flame resistant in accordance with provisions of National Fire Protection Association (NFPA) 101, 10.3. This facility has 21 certified beds and at the time of the survey the census was 10.

Findings include:

1. Observation and interview on 6/1/11, revealed the curtains in the Patient Kitchenette was not tagged as being flame retardant.
2. Observation and interview on 6/1/11, revealed the curtains in the Diabetes Education Training Room were not tagged as being flame retardant.
3. Observation and interview on 6/1/11, revealed the curtain on the closet in the Chief Operating Officer's office was not tagged as being flame retardant.
4. Observation and interview on 6/1/11, revealed the blanket on the wall in the Foundation Director's Office was not tagged as being flame retardant.

Maintenance Staff A verified these observations.

Based on observation and interview, 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.

Findings include:

Observation and interview on 6/3/11, revealed a missing junction box cover in the Basement above the door going upstairs to the Clinic. Maintenance Staff A verified this observation.

Based on observations and interview, 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. This facility has a capacity of 21 and a census of 10 patients.

Findings include:

Observations and interview on 6/1/11, revealed an open junction box on the east wall in the Surgical Mechanical Room. Maintenance Staff A verified this observation.