HospitalInspections.org

Based on observation, the facility failed to provide the 2 hour fire resistance separation between a Garage and the Facility in 1 location. This deficient practice would affect approximately 3 residents within the affected zone. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed a conduit penetration (approximately 1/2 inch in size) located in the 1st Floor Drive Through Ambulance Bay in the South 2 Hour Fire Wall between the Hospital and the Garage.

Based on observations, the facility failed to maintain 5 of approximately 100 doors throughout the facility in proper working condition. This deficient practice would affect approximately 7 residents and 20 staff members. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Kitchen Dishwashing Corridor Door revealed a drying mat located on the floor obstructed the door from closing and latching into the door frame.

2. The 1st Floor Library Corridor Door revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

3. The 1st Floor IV Pump Storage Room revealed the door blocked open by a crash cart.

4. The Specialty Clinic Room 5 revealed the door was blocked open by a garbage can.

5. The Specialty Clinic Room 6 revealed the door was blocked open by a garbage can.

Based on observations, the facility failed to maintain proper 1 hour vertical fire separation between floors and above ceiling spaces in 4 locations. This deficient practice could affect approximately 12 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Kitchen by the Office revealed a vertical sprinkler pipe penetration (approximately 1/2 inch in size).

2. The Kitchen Restroom revealed a vertical sprinkler pipe penetration (approximately 1/4 inch in size).

3. The Kitchen Dishwashing Space revealed a vertical conduit penetration (approximately 1/4 inch in size).

4. The 1st Floor Stairwell Door by the Elevator revealed the door failed to close and latch into the door frame with the swing of the door closer.

Based on observations and interview, the facility failed to maintain 3 of 3 smoke barriers 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. This deficient practice affects all residents and staff within the facility. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The 1st Floor Main Lobby Smoke Barrier revealed a gap (approximately 3 inches by 7 feet in size) located at the top of the Smoke Barrier. This Smoke Barrier also revealed a tube penetration (approximately 1/2 inch in size) located in the center of the barrier above the suspended ceiling.

2. The 1st Floor OB Smoke Barrier revealed a gap (approximately 3 inches by 7 feet in size) located at the top of the Smoke Barrier, a conduit penetration (approximately 1/2 inch in size), a bracket penetration (approximately 1/2 inch in size), and a casing penetration (approximately 1/2 inch by 2 inches in size).

3. The Sleep End Hallway Smoke Barrier revealed a wire bundle penetration (approximately 1/2 inch in size).

The Facility Maintenance Director confirmed these findings on the date of inspection.

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. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 35 residents and a census of 7 residents.

Findings include:

Observations and interview on 8/18/11, revealed the following:

1. The Med Surgical Storage Room revealed the door was not equipped with a self-closing door closer. This room had been changed from a patient room to a storage room.

2. The Station 2 Electrical Equipment Room revealed a vertical conduit penetration (approximately 1/2 inch in size).

3. The OR Recovery Room Soiled Utility Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

4. The OR Soiled Storage Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

5. The OR Oxygen Storage Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

6. The ER Soiled Utility Room revealed 5 vertical conduit penetrations (approximately 1/2 inch in size each) located above the electrical panel.

7. The Basement Elevator Equipment Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer. This room also revealed a conduit penetration (approximately 1/2 inch in size) located in the North Wall.

8. The Basement Telephone Equipment Room revealed a vertical center conduit penetration (approximately 3 inches in size).

9. The Basement Maintenance Workshop revealed the corridor door was being held open with a wire cable.

10. The Basement Boiler Room revealed multiple holes and breaks the fire protectant spray applied to the steel structural beams and the ceiling lid throughout the room.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observation, the facility failed to maintain 1 of approximately 30 doors within the affected zones easily accessible and unobstructed at all times. This deficient practice would affect approximately 3 residents and 10 staff members within the affected zones. The facility had a capacity of 25 residents and census of 7 residents.

Findings include:

Observations on 8/18/11, revealed a cart and an IV stand obstructing the ER Direct Exit Door to the East.

Based on observations, the facility failed to provide proper emergency lighting units in 2 locations within the facility. This deficient practice would affect approximately 2 residents and 6 staff members. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Operating Room 1 revealed the room was not equipped with an emergency lighting unit with battery back up power to ensure no lapse in lighting in the room in the event of a power outage.

2. The Operating Room 2 revealed the room was not equipped with an emergency lighting unit with battery back up power to ensure no laspe in lighting in the room in the event of a power outage.

Based on record review and interview, the facility failed to provide proper testing and documentation of the building's emergency lighting units. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Record review and interview on 8/18/11, revealed the facility failed to provide the proper 30 second monthly testing for the emergency lighting units throughout the facility. Interview with the Maintenance Supervisor revealed the facility only tested the light to ensure the light turned on but did not conduct a 30 second test on a monthly basis.

Based on observation, the facility failed to maintain 1 of 3 exit signs in 1 suite location in proper working condition. This deficient practice would affect approximately 2 residents and 6 staff members within the affected suite. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed the exit sign above the Operating Room Exit Door by the Out Patient Wing failed to illuminate at the time of inspection.

Based on record review, the facility failed provide fire drills at varying dates on 11 of 12 fire drills. This deficient practice would affect all residents within the facility. The facility had a capacity of 20 residents and a census of 19 residents.

Findings include:

Record review on 8/18/11, revealed the facility conducted 11 of 12 fire drills throughout the course of the last year within the last 4 days of each month. Te fire drills indicated were conducted on the following dates: 1/31/11, 2/28/11, 3/31/11, 4/30/11, 5/31/11, 6/30/11, 7/31/11, 8/30/10, 10/29/10, 11/29/10, and 12/31/10.

Based on observations, the facility failed to maintain the building's fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The ER Entry Area revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

2. The Library revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

3. The Specialty Clinic revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

4. The Physical Therapy Hallway revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

5. The Corridor to the Long Term Care Center revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

6. The Operating Room Corridor by the Recover Room revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

Based on observations, the facility failed to provide proper sprinkler protection in 1 location within the facility in accordance with the National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler System, 1999 edition. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Housekeeping Medical Storage Room revealed an upright style sprinkler head (1 of 1) installed where a pendant style sprinkler head would be required.

2. The OB Dictation Room revealed 3 sprinkler heads installed within a space of approximately 10 feet in length.

3. The Long Term Care Housekeeping Close revealed an upright style sprinkler head (1 of 1) installed where a pendant style sprinkler head would be required.

4. The North Housekeeping Closet revealed an upright style sprinkler head (1 of 1) installed where a pendant style sprinkler head would be required.

5. The Drive Through Ambulance Bay Oxygen Storage Room revealed the room was not equipped with a sprinkler.

6. The Drive Through Ambulance Bay revealed a sprinkler head was not installed above the West Overhead Garage Door to protect the area above the Garage door when in the open position.

7. The Laundry Room revealed revealed 2 upright style sprinkler heads (2 of 2) installed where pendant style sprinkler heads would be required.

8. The Women's Locker Room revealed 3 Closets that were not equipped with sprinkler heads.

Based on observations, the facility failed to maintain the building's sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Kitchen Restroom revealed a missing escutcheon ring on a sprinkler head (1 of 1).

2. The Kitchen Dishwashing Area revealed a sprinkler (1 of 1) with a green corrosive material on the head.

3. The ER Medication Room revealed a paint-like substance located on the sprinkler head (1 of 1).

4. The Drive Through Ambulance Bay revealed a paint-like substance on sprinkler heads (2 of 6) located by the Oxygen Storage Room.

5. The X-Ray Changing Room 1 revealed a paint-like substance on the sprinkler head (1 of 1).

6. The Bone Density Room revealed a paint-like substance on the sprinkler head (1 of 1).

7. The Mammography Room revealed a missing escutcheon ring on the sprinkler head (1 of 1).

8. The Main Public Women's Restroom revealed a missing escutcheon ring on a sprinkler head (1 of 1) located in the Corridor.

9. The North Housekeeping Closet revealed a missing escutcheon ring on a sprinkler head (1 of 1).

10. The Conference Room B revealed a missing escutcheon ring on a sprinkler head (1 of 1) located by the 2 Hour Fire Wall.

11. The Long Term Care Housekeeping Closet revealed a missing escutcheon ring on a sprinkler head (1 of 1).

12. The Business Office Restroom revealed a missing escutcheon ring on a sprinkler head (1 of 1).

13. The OR Storage Room revealed a missing escutcheon ring on a sprinkler head (1 of 2).

14. The IT Room by the Respiratory Therapy Room revealed a missing escutcheon ring on a sprinkler head (1 of 1).

15. The Housekeeping Medical Surge Room revealed a missing escutcheon ring on a sprinkler head (1 of 1).

Based on observations, the facility failed to maintain 2 fire extinguishers in 2 smoke zones in accordance with the National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 1998 edition. This deficient practice would affect approximately 5 staff members. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The X-Ray Hall by the CT revealed the fire extinguisher was being obstructed by a cart.

2. The The Telephone Equipment Room revealed the fire extinguisher was not mounted and was sitting on the floor.

Based on record review and interview, the facility failed to maintain the commercial cooking range hood system in accordance with the National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition Section 3-2.5. This deficient practice would affect all staff and residents within the facility. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Record review and interview on 8/18/11, revealed the facility failed to provide the semi-annual inspection for the Range Hood and Ansul System located in the Kitchen. Interview with the Facility Maintenance Director revealed the facility was unaware of the semi-annual inspection requirements.

Based on observation, the facility failed to properly maintain the smoke separation via the suspended ceiling tile in 1 room in 1 smoke zone in proper working condition. This deficient practice would affect approximately 6 staff members. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed the suspended ceiling smoke tiles were missing in the ceiling grid located in the Business Office IT Room.

Based on observation, the facility failed to provide proper signage for the storage of oxygen in 1 room in 1 of 3 smoke zones. This deficient practice would affect approximately 6 staff members and 3 residents. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed the facility failed to provide an oxygen storage sign and a no smoking sign on the Oxygen Storage Room in the Operating Room.

Based on observations, the facility failed to maintain the building's electrical system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect approximately 4 residents within the affected zones. The facility had a capacity of 25 residents and had a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed the following:

1. The Lobby to the Emergency Room revealed an electrical outlet with a burned mark on the faceplate located by the Time-Coder device.

2. The SCU revealed exposed electrical wiring and outlets throughout the room due the facility painting the room.

Based on observation, the facility failed to provide the 2 hour fire resistance separation between a Garage and the Facility in 1 location. This deficient practice would affect approximately 3 residents within the affected zone. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed a conduit penetration (approximately 1/2 inch in size) located in the 1st Floor Drive Through Ambulance Bay in the South 2 Hour Fire Wall between the Hospital and the Garage.

Based on observations, the facility failed to maintain 5 of approximately 100 doors throughout the facility in proper working condition. This deficient practice would affect approximately 7 residents and 20 staff members. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Kitchen Dishwashing Corridor Door revealed a drying mat located on the floor obstructed the door from closing and latching into the door frame.

2. The 1st Floor Library Corridor Door revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

3. The 1st Floor IV Pump Storage Room revealed the door blocked open by a crash cart.

4. The Specialty Clinic Room 5 revealed the door was blocked open by a garbage can.

5. The Specialty Clinic Room 6 revealed the door was blocked open by a garbage can.

Based on observations, the facility failed to maintain proper 1 hour vertical fire separation between floors and above ceiling spaces in 4 locations. This deficient practice could affect approximately 12 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Kitchen by the Office revealed a vertical sprinkler pipe penetration (approximately 1/2 inch in size).

2. The Kitchen Restroom revealed a vertical sprinkler pipe penetration (approximately 1/4 inch in size).

3. The Kitchen Dishwashing Space revealed a vertical conduit penetration (approximately 1/4 inch in size).

4. The 1st Floor Stairwell Door by the Elevator revealed the door failed to close and latch into the door frame with the swing of the door closer.

Based on observations and interview, the facility failed to maintain 3 of 3 smoke barriers 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. This deficient practice affects all residents and staff within the facility. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The 1st Floor Main Lobby Smoke Barrier revealed a gap (approximately 3 inches by 7 feet in size) located at the top of the Smoke Barrier. This Smoke Barrier also revealed a tube penetration (approximately 1/2 inch in size) located in the center of the barrier above the suspended ceiling.

2. The 1st Floor OB Smoke Barrier revealed a gap (approximately 3 inches by 7 feet in size) located at the top of the Smoke Barrier, a conduit penetration (approximately 1/2 inch in size), a bracket penetration (approximately 1/2 inch in size), and a casing penetration (approximately 1/2 inch by 2 inches in size).

3. The Sleep End Hallway Smoke Barrier revealed a wire bundle penetration (approximately 1/2 inch in size).

The Facility Maintenance Director confirmed these findings on the date of inspection.

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. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 35 residents and a census of 7 residents.

Findings include:

Observations and interview on 8/18/11, revealed the following:

1. The Med Surgical Storage Room revealed the door was not equipped with a self-closing door closer. This room had been changed from a patient room to a storage room.

2. The Station 2 Electrical Equipment Room revealed a vertical conduit penetration (approximately 1/2 inch in size).

3. The OR Recovery Room Soiled Utility Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

4. The OR Soiled Storage Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

5. The OR Oxygen Storage Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

6. The ER Soiled Utility Room revealed 5 vertical conduit penetrations (approximately 1/2 inch in size each) located above the electrical panel.

7. The Basement Elevator Equipment Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer. This room also revealed a conduit penetration (approximately 1/2 inch in size) located in the North Wall.

8. The Basement Telephone Equipment Room revealed a vertical center conduit penetration (approximately 3 inches in size).

9. The Basement Maintenance Workshop revealed the corridor door was being held open with a wire cable.

10. The Basement Boiler Room revealed multiple holes and breaks the fire protectant spray applied to the steel structural beams and the ceiling lid throughout the room.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observation, the facility failed to maintain 1 of approximately 30 doors within the affected zones easily accessible and unobstructed at all times. This deficient practice would affect approximately 3 residents and 10 staff members within the affected zones. The facility had a capacity of 25 residents and census of 7 residents.

Findings include:

Observations on 8/18/11, revealed a cart and an IV stand obstructing the ER Direct Exit Door to the East.

Based on observations, the facility failed to provide proper emergency lighting units in 2 locations within the facility. This deficient practice would affect approximately 2 residents and 6 staff members. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Operating Room 1 revealed the room was not equipped with an emergency lighting unit with battery back up power to ensure no lapse in lighting in the room in the event of a power outage.

2. The Operating Room 2 revealed the room was not equipped with an emergency lighting unit with battery back up power to ensure no laspe in lighting in the room in the event of a power outage.

Based on record review and interview, the facility failed to provide proper testing and documentation of the building's emergency lighting units. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Record review and interview on 8/18/11, revealed the facility failed to provide the proper 30 second monthly testing for the emergency lighting units throughout the facility. Interview with the Maintenance Supervisor revealed the facility only tested the light to ensure the light turned on but did not conduct a 30 second test on a monthly basis.

Based on observation, the facility failed to maintain 1 of 3 exit signs in 1 suite location in proper working condition. This deficient practice would affect approximately 2 residents and 6 staff members within the affected suite. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed the exit sign above the Operating Room Exit Door by the Out Patient Wing failed to illuminate at the time of inspection.

Based on record review, the facility failed provide fire drills at varying dates on 11 of 12 fire drills. This deficient practice would affect all residents within the facility. The facility had a capacity of 20 residents and a census of 19 residents.

Findings include:

Record review on 8/18/11, revealed the facility conducted 11 of 12 fire drills throughout the course of the last year within the last 4 days of each month. Te fire drills indicated were conducted on the following dates: 1/31/11, 2/28/11, 3/31/11, 4/30/11, 5/31/11, 6/30/11, 7/31/11, 8/30/10, 10/29/10, 11/29/10, and 12/31/10.

Based on observations, the facility failed to maintain the building's fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The ER Entry Area revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

2. The Library revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

3. The Specialty Clinic revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

4. The Physical Therapy Hallway revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

5. The Corridor to the Long Term Care Center revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

6. The Operating Room Corridor by the Recover Room revealed a smoke detector within 3 feet of an air diffuser located in the corridor.

Based on observations, the facility failed to provide proper sprinkler protection in 1 location within the facility in accordance with the National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler System, 1999 edition. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Housekeeping Medical Storage Room revealed an upright style sprinkler head (1 of 1) installed where a pendant style sprinkler head would be required.

2. The OB Dictation Room revealed 3 sprinkler heads installed within a space of approximately 10 feet in length.

3. The Long Term Care Housekeeping Close revealed an upright style sprinkler head (1 of 1) installed where a pendant style sprinkler head would be required.

4. The North Housekeeping Closet revealed an upright style sprinkler head (1 of 1) installed where a pendant style sprinkler head would be required.

5. The Drive Through Ambulance Bay Oxygen Storage Room revealed the room was not equipped with a sprinkler.

6. The Drive Through Ambulance Bay revealed a sprinkler head was not installed above the West Overhead Garage Door to protect the area above the Garage door when in the open position.

7. The Laundry Room revealed revealed 2 upright style sprinkler heads (2 of 2) installed where pendant style sprinkler heads would be required.

8. The Women's Locker Room revealed 3 Closets that were not equipped with sprinkler heads.

Based on observations, the facility failed to maintain the building's sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The Kitchen Restroom revealed a missing escutcheon ring on a sprinkler head (1 of 1).

2. The Kitchen Dishwashing Area revealed a sprinkler (1 of 1) with a green corrosive material on the head.

3. The ER Medication Room revealed a paint-like substance located on the sprinkler head (1 of 1).

4. The Drive Through Ambulance Bay revealed a paint-like substance on sprinkler heads (2 of 6) located by the Oxygen Storage Room.

5. The X-Ray Changing Room 1 revealed a paint-like substance on the sprinkler head (1 of 1).

6. The Bone Density Room revealed a paint-like substance on the sprinkler head (1 of 1).

7. The Mammography Room revealed a missing escutcheon ring on the sprinkler head (1 of 1).

8. The Main Public Women's Restroom revealed a missing escutcheon ring on a sprinkler head (1 of 1) located in the Corridor.

9. The North Housekeeping Closet revealed a missing escutcheon ring on a sprinkler head (1 of 1).

10. The Conference Room B revealed a missing escutcheon ring on a sprinkler head (1 of 1) located by the 2 Hour Fire Wall.

11. The Long Term Care Housekeeping Closet revealed a missing escutcheon ring on a sprinkler head (1 of 1).

12. The Business Office Restroom revealed a missing escutcheon ring on a sprinkler head (1 of 1).

13. The OR Storage Room revealed a missing escutcheon ring on a sprinkler head (1 of 2).

14. The IT Room by the Respiratory Therapy Room revealed a missing escutcheon ring on a sprinkler head (1 of 1).

15. The Housekeeping Medical Surge Room revealed a missing escutcheon ring on a sprinkler head (1 of 1).

Based on observations, the facility failed to maintain 2 fire extinguishers in 2 smoke zones in accordance with the National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 1998 edition. This deficient practice would affect approximately 5 staff members. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observations on 8/18/11, revealed the following:

1. The X-Ray Hall by the CT revealed the fire extinguisher was being obstructed by a cart.

2. The The Telephone Equipment Room revealed the fire extinguisher was not mounted and was sitting on the floor.

Based on record review and interview, the facility failed to maintain the commercial cooking range hood system in accordance with the National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition Section 3-2.5. This deficient practice would affect all staff and residents within the facility. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Record review and interview on 8/18/11, revealed the facility failed to provide the semi-annual inspection for the Range Hood and Ansul System located in the Kitchen. Interview with the Facility Maintenance Director revealed the facility was unaware of the semi-annual inspection requirements.

Based on observation, the facility failed to properly maintain the smoke separation via the suspended ceiling tile in 1 room in 1 smoke zone in proper working condition. This deficient practice would affect approximately 6 staff members. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed the suspended ceiling smoke tiles were missing in the ceiling grid located in the Business Office IT Room.

Based on observation, the facility failed to provide proper signage for the storage of oxygen in 1 room in 1 of 3 smoke zones. This deficient practice would affect approximately 6 staff members and 3 residents. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed the facility failed to provide an oxygen storage sign and a no smoking sign on the Oxygen Storage Room in the Operating Room.

Based on observations, the facility failed to maintain the building's electrical system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect approximately 4 residents within the affected zones. The facility had a capacity of 25 residents and had a census of 7 residents.

Findings include:

Observation on 8/18/11, revealed the following:

1. The Lobby to the Emergency Room revealed an electrical outlet with a burned mark on the faceplate located by the Time-Coder device.

2. The SCU revealed exposed electrical wiring and outlets throughout the room due the facility painting the room.