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Based on observations and interview, the facility failed to maintain the fire resistance separation in 2 of 2 fire resistance walls. This deficient practice would affect approximately 3 residents and approximately 20 staff members within the affected zones The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room 3 hour fire resistant separation wall to the Emergency Room Garage revealed a conduit penetration (approximately 1/2 inch in size), a copper pipe penetration (approximately 1/2 inch in size), and a flexible conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling, above the Double Fire Doors.

2. The Emergency Room 3 Hour Fire Resistant Separation Wall to the Emergency Room Garage revealed a 1 hour fire resistance wall of sheet rock located above the Double Fire Doors. The Emergency Room Garage revealed a distance of approximately 3 feet between the 3 hour Double Fire Doors and the 3 hour Fire Resistant Separation Wall.

3. The Emergency Room 3 Hour Fire Resistant Separation Wall Double Fire Doors revealed the doors failed to close and latch properly into the door frame with the swing of the door closers. These doors also revealed a gap (approximately 1/2 inch in size) between the doors when they were in the closed position.

4. The 2 Hour Fire Resistant Wall between the Hospital and the Medical Plaza at the East side of the Lower Link revealed a wire tray penetration (approximately 1 foot in size), a 2 wire penetration (approximately 1 inch in size), a conduit penetration (approximately 1 inch in size), and a pipe penetration (approximately 1 inch in size).

5. The 2 Hour Fire Resistant Wall between the Hospital and the Medical Plaza at the East side of the Lower Link revealed 2 windows located within 4 feet of the 2 hour fire barrier that were not rated or protected.

6. The Medical Arts Plaza Lower Link Exit Double Fire Doors revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

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

Based on observations and staff interview, it was determined the facility was a two-story building and consisted of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were properly maintained. This deficient practice affects 2 of approximately 5 protected rooms and approximately 20 staff members. The facility had a capacity of 25 residents and a census of 4 residents at the time of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room Garage revealed multiple penetrations (approximately 1 inch to 4 inches in size each) in the sprayed fire resistant coating to the Steel Structural Beams within the Garage. These areas of removed fire resistant coating were due to the installation of utilities.

2. The 1st Floor Radiology Air Handler/Mechanical Room revealed multiple penetrations (approximately 1 inch to 4 inches in size each) in the sprayed fire resistant coating to the Steel Structural Beams within the room. These areas of removed fire resistant coating were due to the installation of utilities.

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

Based on observation and interview, the facility failed to maintain 1 of approximately 30 corridor room walls within 1 of 20 smoke zones properly separated from the corridor. This deficient practice could affect approximately 5 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observation and interview on 3/21/12, revealed a hole (approximately 1 inch in size) located above the light switch in the 2nd Floor Medication Room. The Facility Assistant Director of Facilities confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 6 of approximately 60 doors in 5 of 20 smoke zones in proper working condition. This deficient practice would affect approximately 30 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Internal Medicine Break Room Door revealed the door was wedged open at the time of inspection.

2. The Internal Medicine File Room Door revealed the door was wedged open at the time of inspection.

3. The MRI Control Room 170 Door revealed the door was wedged open at the time of inspection.

4. The Purchasing Room Door revealed the door closer was detached from the door at the time of inspection.

5. The Cafeteria Door by the Conference Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

6. The Medical Plaza Sports Medicine Procedure Room revealed the door was wedged open at the time of inspection.

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

Based on observations and interview, the facility failed to maintain proper 1 hour vertical fire separation in 4 locations. This deficient practice could affect approximately 4 residents within the 4 of 20 smoke zones. The facility had a capacity of 4 residents and a census of 25 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Basement Stairwell to the 1st Floor revealed 2 conduit penetrations (approximately 1/2 inch in size each) and a sprinkler pipe penetration (approximately 1/2 inch in size) located above the 1st Floor door.

2. The Surgery Sterilization Room revealed a vertical pipe penetration (approximately 1/2 inch in size).

3. The Kitchen Pantry revealed 2 vertical electrical conduit penetrations (approximately 1/2 inch in size each) located above the Electrical Panel.

4. The Stairwell to the 2nd Floor Patient Area revealed a sprinkler pipe penetration (approximately 1/2 inch in size) located above the Stairwell Door.

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

Based on observations and interview, the facility failed to provide illuminated exit signs in 3 locations in 2 of 20 smoke zones to properly indicate the direction of travel to exit. This deficient practice would affect approximately 10 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The 1st Floor Hallway by Office 173 revealed the Double Doors failed to be provided with an illuminated exit sign to the West Side of the doors.

2. The 1st Floor Radiology Hallway failed to be provided with an illuminated exit sign on the West Side of the Hallway.

3. The Boiler Room revealed the North Exit Sign was installed in a location that it was obstructed by overhead pipes and other mechanical works.

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

Based on observations and interview, the facility failed to maintain 10 of 20 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 4 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room Side Door Smoke Barrier revealed 2 copper pipe penetrations (approximately 1/2 inch in size each) located above the suspended ceiling.

2. The Rehabilitation Smoke Barrier above Door 129 revealed 2 wire penetrations (approximately 1 inch in size each) and a pipe penetration (approximately 2 inches in size) located above the suspended ceiling.

3. The Double Fire Doors Smoke Barrier by Basement Stairwell revealed a conduit bundle penetration (approximately 6 inches in size, a conduit penetration (approximately 3 inches in size), a conduit penetration (approximately 6 inches in size), and a wrapped pipe penetration (approximately 3 inches in size) located above the suspended ceiling.

4. The Double Doors from the Emergency Room to the Cancer Center revealed a flexible conduit penetration (approximately 1 foot by 6 inches in size) and a hole (approximately 1 inch in size) located above the suspended ceiling.

5. The Radiology Smoke Barrier by Nuclear Medicine revealed 3 wire bundle penetrations (approximately 1 inch to 3 inches in size each), 3 conduit penetrations (approximately 1/2 inch to 3 inches in size each), and a duct penetration (approximately 1 foot in size) located above the suspended ceiling.

6. The Radiology Smoke Barrier revealed 4 center conduit penetrations (approximately 1/2 inch in size each) and a hole (approximately 18 inches in size) with old insulation foam located above the ceiling.

7. The Double Doors Smoke Barrier by the Maintenance Room on the 1st Floor revealed 3 conduit penetrations (approximately 1 inch to 3 inches in size each) and a copper pipe penetration (approximately 1/2 inch in size) located above the suspended ceiling.

8. The 2nd Floor 300 Hall Smoke Barrier revealed 3 center conduit penetrations (approximately 1/2 inch to 1 inch in size each), a black pipe penetration (approximately 1/2 inch in size), and a flexible conduit penetration (approximately 1 inch in size) located above the suspended ceiling.

9. The 2nd Floor 200 Hall Smoke Barrier revealed a wire penetration (approximately 5 inches in size) located above the suspended ceiling.

10. The Medical Plaza 1st Floor Smoke Barrier to the Suites revealed a conduit penetration (approximately 1/2 inch in size) located in the Smoke Barrier above the Suite 150 Entrance Door, a hole (approximately 1/2 inch in size) located in the Smoke Barrier above the Suite 110 (Morning Star Clinic) Entrance Door, and a board penetration (approximately 2 inches in size) located above the Suite 100 (New Life Clinic) Entrance Door.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 5 of 20 sets of smoke barrier doors in proper working condition. This deficient practice would affect approximately 20 staff members within the facility. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Double Fire Doors by the Basement Stairs revealed the doors overlapped and failed to close and latch properly into the door frame when tested.

2. The Radiology Smoke Barrier Doors revealed a gap (approximately 1/2 inch in size) located between the doors when they were in the closed position.

3. The 2nd Floor Administration Wing Smoke Barrier Doors revealed a gap (approximately 1 inch in size) located between the doors when the doors were in the closed position.

4. The 2nd Floor 200 Hall Smoke Barrier Doors by Room 102 revealed the doors failed to close and latch properly into the door frame due to the doors rubbing together.

5. The Fire Doors outside the Rehabilitation Side Door revealed a gap (approximately 1/2 inch in size) between the doors when the doors were in the closed position.

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

Based on observations and staff interview, the facility failed to provide proper separation of 26 of approximately 55 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 all residents and staff throughout the affected zones. The facility had a capacity of 25 residents and a census of 4 residents.


Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room Electrical Room revealed a conduit penetrations (approximately 2 inches in size) located by the west wall.

2. The Emergency Room Soiled Utility Room revealed the door latching hardware failed to close and latch properly into the door frame due to the hardware sticking.

3. The Emergency Room Garage Storage Room 255 revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

4. The Mechanical Room 266 revealed a duct damper penetration (approximately 1/2 inch size) located on the east wall and a duct damper penetration (approximately 1/2 inch in size) located on the north wall.

5. The Telecom/IT Room 435 revealed a conduit penetration (approximately 1 inch in size) located in the corridor wall.

6. The Electrical Room 436 revealed 3 center conduit penetrations (approximately 1/2 inch in size each)located in the corridor wall.

7. The Electrical Room 437 revealed a hole (approximately 1 inch in size) located in the south wall above Electrical Panel LCR, a center conduit penetration (approximately 1/2 inch in size) located in the east wall, a conduit penetration (approximately 1/2 inch in size) located in the east wall, and a conduit penetration (approximately 1/2 inch in size) located in the East wall.

8. The Medical Plaza Electrical Room revealed a conduit penetration (approximately 1 inch in size) located in the South Wall above the Fire Alarm Extender Unit.

9. The Medical Records Storage Room located that the Top of the Link revealed a conduit penetration (approximately 6 inches in size) located in the Southeast Wall and a wire tray penetration (approximately 6 inches in size) located in the Northwest Wall.

10. The Basement Mechanical Area revealed multiple vertical pipe and conduit penetrations (approximately 1/2 inch up to 6 inches in size each) located in the ceiling lid throughout the Basement Area.

11. The Radiology Air Handler/Mechanical Room revealed a conduit bundle penetration (approximately 1 foot in size) located in the corridor wall, 2 copper pipe penetrations (approximately 1/2 inch in size), a conduit penetration (approximately 6 inches in size), a wire tray penetration (approximately 6 inches in size), and the door failed to close and latch properly into the door frame with the swing of the door closer.

12. The Surgery Storage Room revealed the door was wedged open at the time of inspection.

13. The Maintenance Mechanical Room revealed multiple holes (approximately 1 inch to 2 feet in size each) with orange expanding foam within the holes and a conduit penetration (approximately 1 inch in size) located above the "Normal Power" Electrical Panel.

14. The Boiler Room revealed the West door failed to close and latch properly into the door frame with the swing of the door closer due to the door sticking.

15. The Boiler Room revealed 2 holes (approximately 4 inches in size) located in the west wall.

16. The 2nd Floor Storage by the Family Waiting Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

17. The 2nd Floor Administration Wing Storage Room revealed a vertical duct penetration (approximately 1/4 inch in size).

18. The 2nd Floor 300 Hall Utility Room revealed 2 center conduit penetrations (approximately 1/2 inch in size each).

19. The 2nd Floor Storage Room by the Medication Room revealed the door failed to close and latch properly into the door frame due the door latching hardware being taped down. This room also revealed multiple holes and penetrations (approximately 1 inch to 6 inches in size each) due to construction taking place at the time of inspection.

20. The Elevator Equipment Room revealed a vertical pipe penetration (approximately 1/2 inch in size) located in the ceiling lid of the room.

21. The New Mechanical (Purchasing) Room revealed 2 conduit penetrations (approximately 1/2 inch in size) located above the doors, 2 conduit penetrations (approximately 1/2 inch in size) located in the west wall, and a pipe penetration (approximately 1/2 inch in size) located in the west wall.

22. The Kitchen/Laundry Mechanical Room revealed the door was not properly equipped with a door closer device, the south wall of the room revealed 4 conduit penetrations (approximately 1/2 inch in size) and the west wall of the room revealed a pipe penetration (approximately 1/2 inch in size).

23. The Storage Room 208 revealed the door was not properly equipped with a door closer device.

24. The Nurse's Station IT Room revealed multiple wire bundle, conduits, and hole penetrations (approximately 1/2 inch to 2 feet in size each) throughout the room due to construction taking place at the time of inspection.

25. The Nurse's Station Electrical Room revealed multiple conduit, pipes, and hole penetrations (approximately 1/2 inch to 2 feet in size each) throughout the room due to construction taking place at the time of inspection.

26. The Outreach Clinic Back Hallway Electrical Room/Housekeeping Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 4 of 100 doors and hallways clear and unobstructed at all times. This deficient practice would affect approximately 4 residents and 40 staff members within the affected zones. The facility had a capacity of 25 residents and census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Medical Arts Lower Link Exit Pathway by the Maintenance Rooms revealed the corridor was obstructed by chairs and a garbage cart.

2. The 2nd Floor Back Stairwell Door revealed the door was a 15 Second Delayed Egress Door that was not provided with a sign indicating that there was a 15 Second Delay to exit.

3. The 1st Floor Purchasing Hallway revealed storage items within the Hallway that obstructed the width of the corridor.

4. The 2nd Floor In-Patient Area revealed multiple storage items and construction tools within the hallways that obstructs the width of the corridor. This Area was under construction at the time of inspection and had not been approved for occupancy as of the time of the inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations, record review, and interview, the facility failed to maintain the building's emergency lighting units in proper working condition and within proper testing requirements. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 3/21/12, revealed the following:

1. The Medical Clinic West Housekeeping Hallway revealed the emergency lighting unit failed to illuminate when tested.

2. Record review of the Emergency Lighting Testing revealed the emergency lighting unit by Electrical Room 432 was not tested in April or November of 2011 for the 30 second monthly test and failed to be tested for annual 90 minute testing.

3. Record review of the Emergency Lighting Testing revealed the lights in the Main Building 1st Floor failed to receive a 90 minute annual test, the emergency lighting units in the Main Building Ground Floor failed to receive a 90 minute annual test, and the Emergency Lighting Testing Documentation failed to indicate the locations of all emergency lighting units.

4. The Top of the Link Double Door Exit revealed the emergency lighting unit by the door failed to illuminate when tested.

The Assistant Director of Facilities confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed to maintain 2 exit signs in 2 of 20 smoke zones in proper working condition. This deficient practice would affect approximately 15 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observation and interview on 3/21/12, revealed the following:

1. The Top of the Link Double Exit Doors revealed the exit sign failed to illuminate at the time of inspection.

2. The 1st Floor Dietary Director's Office outside of the Director's Office revealed the exit sign failed to illuminate at the time of inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide the proper number of fire drills over a year and failed to properly vary the times and dates of the fire drills that were conducted. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Record review and interview on 3/21/12, revealed the following:

1. Record review of the fire drills conducted in the last year revealed the facility failed to provide a fire drill for the 2nd Shift of the 3rd Quarter within the last year.

2. Record review of the fire drill documentation revealed the 3rd Shift Fire Drills conducted in the 1st, 2nd, and 3rd Quarters of the last year were all conducted within the 1100 p.m. hour (1st Quarter-1148 p.m., 2nd Quarter-1100 pm, and 3rd Quarter-1130 p.m.)

3. Record review of the fire drill documentation revealed the 2nd Shift Fire Drills conducted in the 1st, 2nd, and 4th Quarters of the last year were all conducted within the 3:00 p.m. hour (1st Quarter-3:24 p.m., 2nd Quarter-3:00 p.m., and 4th Quarter- 3:31 p.m.)

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, 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 all residents throughout the building. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Fire Alarm Annunciator Panel in the Emergency Room Entrance revealed the Fire Alarm System was in Trouble at the time of inspection. Interview with the Assistant Director of Facilities stated the system was in trouble due to construction.

2. The Emergency Room Corridor outside Room 1 (238) revealed a smoke detector within 3 feet of a air diffuser.

3. The Internal Medicine File Room revealed an single station smoke detector that was no longer in use.

4. The Medical Plaza IT Room revealed a smoke detector installed within 3 feet of an air diffuser.

5. The Laundry Room North Double Doors revealed when the door is held open the door obstructs the fire alarm pull station and the fire alarm horn/strobe devices that were located behind the door.

6. The Locker Room by the Cafeteria revealed the Fire Alarm Horn/Strobe unit was disconnected from the wall.

7. The Medical Clinic West Housekeeping Hallway revealed a smoke detector installed within 3 feet of an air diffuser.

8. The 2nd Floor In-Patient Area revealed the smoke detectors throughout this area were covered by dust covers due to construction within the area. At the time of inspection, this area was under major construction and had not been approved for occupancy as of the date of inspection.

9. The Lab Waiting Room Area revealed a smoke detector installed within 3 feet of an air diffuser.
The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to provide proper sprinkler protection in 6 locations 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 and staff within the facility. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Medical Arts Sprinkler Riser Room revealed the Spare Sprinkler Head Box contained only 5 spare sprinkler heads.

2. The X-Ray Room 2 revealed the X-Ray Machine Ceiling Supports were installed within 2 inches of the sprinkler heads.

3. The Pharmacy Storage Closet revealed the closet was not provided with any sprinkler coverage.

4. The Housekeeping Room by the Cafeteria revealed the room was not provided with any sprinkler coverage.

5. The Men's Locker Room by the Cafeteria revealed the room was not provided with any sprinkler coverage.

6. The Stairwell to the OB Room 101 revealed the Stairwell was not provided with any sprinkler coverage at the 2nd Floor level.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations, record review, and interview, the facility failed to maintain the building's sprinkler system in proper working condition 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 all residents and staff within the facility. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 3/21/12, revealed the following:

1. The Cashier's Room revealed a sprinkler head (1 of 1) missing a cover.

2. The Main Entrance Lobby revealed a sprinkler head with a missing cover.

3. The Area Outside the Rehabilitation Door revealed a sprinkler head (1 of 5) missing a cover.

4. The Rehabilitation New Pool Room revealed the sprinkler heads (4 of 4) were covered due to the area being under construction.

5. The 1st Floor Corridor by the Maintenance Room revealed 2 sprinkler heads missing escutcheon rings.

6. The X-Ray Restroom revealed the sprinkler escutcheon ring was dropped from the sprinkler head (1 of 1).

7. The Nuclear Medicine Room revealed a escutcheon ring missing on a sprinkler head (1 of 2).

8. The 1st Floor directly outside Dietary Director's Office revealed a sprinkler head missing a cover (1 of 18).

9. The Cafeteria Door by the Gift Store revealed a missing cover on a sprinkler head.

10. The Cafeteria by the Entrees revealed a missing cover on the sprinkler head (1 of 8).

11. The Medical Plaza Outreach Clinic Back Hallway Restroom revealed a sprinkler head missing an escutcheon ring (1 of 1).

12. The Medical Plaza Outreach Clinic Restroom by the Electrical/Housekeeping Room revealed a sprinkler head missing an escutcheon ring (1 of 1).

13. The Medical Plaza Back Stairwell revealed a sprinkler head missing an escutcheon ring (1 of 2).

14. The Medical Plaza Sports Medicine Film Storage Room revealed the drop sprinkler heads were dropped below the ceiling tiles.

15. The Medical Plaza Sports Medicine Nurse's Office revealed a sprinkler head missing a cover (1 of 1).

16. The Medical Clinic Storage Room by the Soiled Utility Room revealed a sprinkler head missing an escutcheon ring (1 of 1).

17. The Medical Clinic Storage Room by the Soiled Utility Room revealed storage materials within 18 inches of the sprinkler head.

18. The Medical Clinic Storage Room by Room C6 revealed a missing escutcheon ring on the sprinkler head (1 of 1).

19. The Medical Clinic Exam Room 7 revealed a missing escutcheon ring on the sprinkler head (1 of 1)

20. The Medical Clinic Housekeeping Room by the Records Storage revealed a missing escutcheon ring on the sprinkler head (1 of 1).

21. The Medical Clinic Restroom by the Lab Testing revealed a missing escutcheon ring on the sprinkler head (1 of 1).

22. The 2nd Floor Office 1005 revealed the sprinkler head had dropped below the level of the suspended ceiling.

23. The 2nd Floor In-Patient Area revealed the sprinkler heads throughout the area were covered due to construction of the area. This area was still under major construction and had not been approved for occupancy as of the date of inspection.

24. Record review of the Sprinkler Inspection Documentation from 12/27/11 revealed the "Old Behavior Unit Control Valve does not send a signal to the panel,""the facility needs to re-install inspector's test for patients water flow switch at a new location, several areas under construction," and "low air and tamper switch to MRI can only be read at the MRI panel." Interview with the Assistant Director of Facilities revealed the facility could not provide documentation stating the deficiencies had been corrected.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to provide fire extinguishers in 2 of 20 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 25 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The 2nd Floor In-Patient Entry Area revealed the facility failed to provide any fire extinguishers throughout the area due to it being under major construction at the time of inspection. At the time of inspection, this area was under major construction and had not been given occupancy approved as of the date of inspection.

2. The Medical Plaza IT Room revealed the fire extinguisher was not mounted and was sitting on the floor.

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

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 occupants within the affected area. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Record review and interview on 3/21/12, revealed the Range Hood Inspection Documentation indicated the Range Hood had "No shunt trip to shut off the electricity." Interview with the Assistant Director of Facilities revealed the facility had yet to correct the found deficiency. The Assistant Director of Facilities confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the suspended ceiling tile grid throughout the facility in proper placement. This deficient practice could affect all residents and staff within the affected zones. The facility had a capacity of 25 residents and a census of 4 residents at the time of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room Breezeway to the Garage revealed the suspended ceiling tiles were out of place.

2. The 1st Floor Radiology Smoke Barrier revealed the suspended ceiling tiles were out of place due to construction.

3. The 1st Floor X-Ray IT Room revealed there were missing suspended ceiling tiles.

4. The 1st Floor X-Ray Changing Room revealed the suspended ceiling tiles were out of place.

5. The 1st Floor Dietary Director's Office revealed the suspended ceiling tiles were removed due to construction work in this room.

6. The 2nd Floor In-Patient Entry Area revealed the suspended ceiling tiles were not completely installed due to the area being under major construction and had not been approved for occupancy as of the date of inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain proper storage of flammable liquids in 1 room in 1 of 20 smoke zones. This deficient practice would affect approximately 3 residents within the affected zone. The facility had a capacity of 25 residents and a census of 4 residents at the time of inspection.

Findings include:

Observation and interview on 3/21/12, revealed an Liquifed Petroleum (LP) tank and a full 5 gallon gasoline canister were sitting on the floor of the Emergency Room Ambulance Garage Storage Room. The Assistant Director of Facilities confirmed this finding on the date of inspection.

Based on observations and interview, 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 all residents and staff within the affected zones. The facility had a capacity of 25 residents and had a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Operator/Cashier Area revealed a refrigerator, a microwave, and a coffee pot plugged into a plastic surge protector.

2. The Rehabilitation Room New Pool Room revealed multiple open electrical junction boxes due to construction within this room on the date of inspection.

3. The Emergency Room Electrical Room revealed an electrical pull box on a conduit located above Electrical Panel LNE without a cover.

4. The Electrical Room 436 revealed an electrical run box located on the corridor wall did not have a cover on the box.

5. The Electrical Room 437 revealed an electrical run box without a cover located above the East wall door and 2 electrical outlets on the corridor wall without covers.

6. The 2 Hour Fire Resistance Barrier to the Medical Plaza revealed an open electrical junction box located in the center of the Barrier above the suspended ceiling.

7. The Medical Arts Plaza Lower Link Exit Doors revealed an open electrical junction box located above the suspended ceiling.

8. The Medical Plaza Electrical Room revealed the storage of tables and chairs within 3 feet of the electrical panels within the room.

9. The Basement revealed an open electrical junction box on the ceiling lid located in front of the Variable Speed Drive.

10. The 1st Floor Maintenance Mechanical Room revealed storage within 3 feet of the "Normal Power" Electrical Panel.

11. The Maintenance Director's Office revealed exposed electrical wires located on the ceiling deck.

12. The Boiler Room by the Maintenance Garage revealed an open electrical junction box on the ceiling by the Door to the Maintenance Garage.

13. The 2nd Floor Electrical Panels CNIPW located by the Bathing Rooms revealed Electrical Breakers 1, 3, 4, 7, 6, 11, 18, 20, 21, 26, 28, 31, 32, 34, 35, 36, 39, 40, 42, 43, 44, 52, and 54 were not labeled.

14. The 1st Floor Dietary Director's Office revealed multiple electrical junction boxes were not properly covered due to construction.

15. The 1st Floor Pantry revealed storage items within 3 feet of the electrical panels within the room.

16. The 2nd Floor In-Patient Area revealed exposed electrical wiring and electrical junction boxes throughout the area due to major construction in the area. This area was under major construction and had not been approved for occupancy at the time of inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain Alcohol-Based Hand Rub in accordance with Section 19.3.2.7 of the 2000 Life Safety Code. This deficient practice would affect approximately 5 staff members. The facility had a capacity of 68 residents and a census of 57 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Corridor directly outside the Conference Room revealed the alcohol-based hand rub was installed within 3 inches from the light switch.

2. The Rehabilitation Speech Pathology Room 128 revealed an alcohol-based hand rub was installed directly over a light switch.

3. The Rehabilitation Treatment Room B131 revealed an alcohol-based hand rub was installed directly over a light switch.

4. The Rehabilitation Treatment Room C131 revealed an alcohol-based hand rub was installed directly over a light switch.

5. The Rehabilitation Treatment Room D131 revealed an alcohol-based hand rub was installed directly over a light switch.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain the fire resistance separation in 2 of 2 fire resistance walls. This deficient practice would affect approximately 3 residents and approximately 20 staff members within the affected zones The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room 3 hour fire resistant separation wall to the Emergency Room Garage revealed a conduit penetration (approximately 1/2 inch in size), a copper pipe penetration (approximately 1/2 inch in size), and a flexible conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling, above the Double Fire Doors.

2. The Emergency Room 3 Hour Fire Resistant Separation Wall to the Emergency Room Garage revealed a 1 hour fire resistance wall of sheet rock located above the Double Fire Doors. The Emergency Room Garage revealed a distance of approximately 3 feet between the 3 hour Double Fire Doors and the 3 hour Fire Resistant Separation Wall.

3. The Emergency Room 3 Hour Fire Resistant Separation Wall Double Fire Doors revealed the doors failed to close and latch properly into the door frame with the swing of the door closers. These doors also revealed a gap (approximately 1/2 inch in size) between the doors when they were in the closed position.

4. The 2 Hour Fire Resistant Wall between the Hospital and the Medical Plaza at the East side of the Lower Link revealed a wire tray penetration (approximately 1 foot in size), a 2 wire penetration (approximately 1 inch in size), a conduit penetration (approximately 1 inch in size), and a pipe penetration (approximately 1 inch in size).

5. The 2 Hour Fire Resistant Wall between the Hospital and the Medical Plaza at the East side of the Lower Link revealed 2 windows located within 4 feet of the 2 hour fire barrier that were not rated or protected.

6. The Medical Arts Plaza Lower Link Exit Double Fire Doors revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

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

Based on observations and staff interview, it was determined the facility was a two-story building and consisted of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were properly maintained. This deficient practice affects 2 of approximately 5 protected rooms and approximately 20 staff members. The facility had a capacity of 25 residents and a census of 4 residents at the time of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room Garage revealed multiple penetrations (approximately 1 inch to 4 inches in size each) in the sprayed fire resistant coating to the Steel Structural Beams within the Garage. These areas of removed fire resistant coating were due to the installation of utilities.

2. The 1st Floor Radiology Air Handler/Mechanical Room revealed multiple penetrations (approximately 1 inch to 4 inches in size each) in the sprayed fire resistant coating to the Steel Structural Beams within the room. These areas of removed fire resistant coating were due to the installation of utilities.

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

Based on observation and interview, the facility failed to maintain 1 of approximately 30 corridor room walls within 1 of 20 smoke zones properly separated from the corridor. This deficient practice could affect approximately 5 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observation and interview on 3/21/12, revealed a hole (approximately 1 inch in size) located above the light switch in the 2nd Floor Medication Room. The Facility Assistant Director of Facilities confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 6 of approximately 60 doors in 5 of 20 smoke zones in proper working condition. This deficient practice would affect approximately 30 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Internal Medicine Break Room Door revealed the door was wedged open at the time of inspection.

2. The Internal Medicine File Room Door revealed the door was wedged open at the time of inspection.

3. The MRI Control Room 170 Door revealed the door was wedged open at the time of inspection.

4. The Purchasing Room Door revealed the door closer was detached from the door at the time of inspection.

5. The Cafeteria Door by the Conference Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

6. The Medical Plaza Sports Medicine Procedure Room revealed the door was wedged open at the time of inspection.

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

Based on observations and interview, the facility failed to maintain proper 1 hour vertical fire separation in 4 locations. This deficient practice could affect approximately 4 residents within the 4 of 20 smoke zones. The facility had a capacity of 4 residents and a census of 25 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Basement Stairwell to the 1st Floor revealed 2 conduit penetrations (approximately 1/2 inch in size each) and a sprinkler pipe penetration (approximately 1/2 inch in size) located above the 1st Floor door.

2. The Surgery Sterilization Room revealed a vertical pipe penetration (approximately 1/2 inch in size).

3. The Kitchen Pantry revealed 2 vertical electrical conduit penetrations (approximately 1/2 inch in size each) located above the Electrical Panel.

4. The Stairwell to the 2nd Floor Patient Area revealed a sprinkler pipe penetration (approximately 1/2 inch in size) located above the Stairwell Door.

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

Based on observations and interview, the facility failed to provide illuminated exit signs in 3 locations in 2 of 20 smoke zones to properly indicate the direction of travel to exit. This deficient practice would affect approximately 10 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The 1st Floor Hallway by Office 173 revealed the Double Doors failed to be provided with an illuminated exit sign to the West Side of the doors.

2. The 1st Floor Radiology Hallway failed to be provided with an illuminated exit sign on the West Side of the Hallway.

3. The Boiler Room revealed the North Exit Sign was installed in a location that it was obstructed by overhead pipes and other mechanical works.

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

Based on observations and interview, the facility failed to maintain 10 of 20 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 4 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room Side Door Smoke Barrier revealed 2 copper pipe penetrations (approximately 1/2 inch in size each) located above the suspended ceiling.

2. The Rehabilitation Smoke Barrier above Door 129 revealed 2 wire penetrations (approximately 1 inch in size each) and a pipe penetration (approximately 2 inches in size) located above the suspended ceiling.

3. The Double Fire Doors Smoke Barrier by Basement Stairwell revealed a conduit bundle penetration (approximately 6 inches in size, a conduit penetration (approximately 3 inches in size), a conduit penetration (approximately 6 inches in size), and a wrapped pipe penetration (approximately 3 inches in size) located above the suspended ceiling.

4. The Double Doors from the Emergency Room to the Cancer Center revealed a flexible conduit penetration (approximately 1 foot by 6 inches in size) and a hole (approximately 1 inch in size) located above the suspended ceiling.

5. The Radiology Smoke Barrier by Nuclear Medicine revealed 3 wire bundle penetrations (approximately 1 inch to 3 inches in size each), 3 conduit penetrations (approximately 1/2 inch to 3 inches in size each), and a duct penetration (approximately 1 foot in size) located above the suspended ceiling.

6. The Radiology Smoke Barrier revealed 4 center conduit penetrations (approximately 1/2 inch in size each) and a hole (approximately 18 inches in size) with old insulation foam located above the ceiling.

7. The Double Doors Smoke Barrier by the Maintenance Room on the 1st Floor revealed 3 conduit penetrations (approximately 1 inch to 3 inches in size each) and a copper pipe penetration (approximately 1/2 inch in size) located above the suspended ceiling.

8. The 2nd Floor 300 Hall Smoke Barrier revealed 3 center conduit penetrations (approximately 1/2 inch to 1 inch in size each), a black pipe penetration (approximately 1/2 inch in size), and a flexible conduit penetration (approximately 1 inch in size) located above the suspended ceiling.

9. The 2nd Floor 200 Hall Smoke Barrier revealed a wire penetration (approximately 5 inches in size) located above the suspended ceiling.

10. The Medical Plaza 1st Floor Smoke Barrier to the Suites revealed a conduit penetration (approximately 1/2 inch in size) located in the Smoke Barrier above the Suite 150 Entrance Door, a hole (approximately 1/2 inch in size) located in the Smoke Barrier above the Suite 110 (Morning Star Clinic) Entrance Door, and a board penetration (approximately 2 inches in size) located above the Suite 100 (New Life Clinic) Entrance Door.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 5 of 20 sets of smoke barrier doors in proper working condition. This deficient practice would affect approximately 20 staff members within the facility. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Double Fire Doors by the Basement Stairs revealed the doors overlapped and failed to close and latch properly into the door frame when tested.

2. The Radiology Smoke Barrier Doors revealed a gap (approximately 1/2 inch in size) located between the doors when they were in the closed position.

3. The 2nd Floor Administration Wing Smoke Barrier Doors revealed a gap (approximately 1 inch in size) located between the doors when the doors were in the closed position.

4. The 2nd Floor 200 Hall Smoke Barrier Doors by Room 102 revealed the doors failed to close and latch properly into the door frame due to the doors rubbing together.

5. The Fire Doors outside the Rehabilitation Side Door revealed a gap (approximately 1/2 inch in size) between the doors when the doors were in the closed position.

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

Based on observations and staff interview, the facility failed to provide proper separation of 26 of approximately 55 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 all residents and staff throughout the affected zones. The facility had a capacity of 25 residents and a census of 4 residents.


Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room Electrical Room revealed a conduit penetrations (approximately 2 inches in size) located by the west wall.

2. The Emergency Room Soiled Utility Room revealed the door latching hardware failed to close and latch properly into the door frame due to the hardware sticking.

3. The Emergency Room Garage Storage Room 255 revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

4. The Mechanical Room 266 revealed a duct damper penetration (approximately 1/2 inch size) located on the east wall and a duct damper penetration (approximately 1/2 inch in size) located on the north wall.

5. The Telecom/IT Room 435 revealed a conduit penetration (approximately 1 inch in size) located in the corridor wall.

6. The Electrical Room 436 revealed 3 center conduit penetrations (approximately 1/2 inch in size each)located in the corridor wall.

7. The Electrical Room 437 revealed a hole (approximately 1 inch in size) located in the south wall above Electrical Panel LCR, a center conduit penetration (approximately 1/2 inch in size) located in the east wall, a conduit penetration (approximately 1/2 inch in size) located in the east wall, and a conduit penetration (approximately 1/2 inch in size) located in the East wall.

8. The Medical Plaza Electrical Room revealed a conduit penetration (approximately 1 inch in size) located in the South Wall above the Fire Alarm Extender Unit.

9. The Medical Records Storage Room located that the Top of the Link revealed a conduit penetration (approximately 6 inches in size) located in the Southeast Wall and a wire tray penetration (approximately 6 inches in size) located in the Northwest Wall.

10. The Basement Mechanical Area revealed multiple vertical pipe and conduit penetrations (approximately 1/2 inch up to 6 inches in size each) located in the ceiling lid throughout the Basement Area.

11. The Radiology Air Handler/Mechanical Room revealed a conduit bundle penetration (approximately 1 foot in size) located in the corridor wall, 2 copper pipe penetrations (approximately 1/2 inch in size), a conduit penetration (approximately 6 inches in size), a wire tray penetration (approximately 6 inches in size), and the door failed to close and latch properly into the door frame with the swing of the door closer.

12. The Surgery Storage Room revealed the door was wedged open at the time of inspection.

13. The Maintenance Mechanical Room revealed multiple holes (approximately 1 inch to 2 feet in size each) with orange expanding foam within the holes and a conduit penetration (approximately 1 inch in size) located above the "Normal Power" Electrical Panel.

14. The Boiler Room revealed the West door failed to close and latch properly into the door frame with the swing of the door closer due to the door sticking.

15. The Boiler Room revealed 2 holes (approximately 4 inches in size) located in the west wall.

16. The 2nd Floor Storage by the Family Waiting Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

17. The 2nd Floor Administration Wing Storage Room revealed a vertical duct penetration (approximately 1/4 inch in size).

18. The 2nd Floor 300 Hall Utility Room revealed 2 center conduit penetrations (approximately 1/2 inch in size each).

19. The 2nd Floor Storage Room by the Medication Room revealed the door failed to close and latch properly into the door frame due the door latching hardware being taped down. This room also revealed multiple holes and penetrations (approximately 1 inch to 6 inches in size each) due to construction taking place at the time of inspection.

20. The Elevator Equipment Room revealed a vertical pipe penetration (approximately 1/2 inch in size) located in the ceiling lid of the room.

21. The New Mechanical (Purchasing) Room revealed 2 conduit penetrations (approximately 1/2 inch in size) located above the doors, 2 conduit penetrations (approximately 1/2 inch in size) located in the west wall, and a pipe penetration (approximately 1/2 inch in size) located in the west wall.

22. The Kitchen/Laundry Mechanical Room revealed the door was not properly equipped with a door closer device, the south wall of the room revealed 4 conduit penetrations (approximately 1/2 inch in size) and the west wall of the room revealed a pipe penetration (approximately 1/2 inch in size).

23. The Storage Room 208 revealed the door was not properly equipped with a door closer device.

24. The Nurse's Station IT Room revealed multiple wire bundle, conduits, and hole penetrations (approximately 1/2 inch to 2 feet in size each) throughout the room due to construction taking place at the time of inspection.

25. The Nurse's Station Electrical Room revealed multiple conduit, pipes, and hole penetrations (approximately 1/2 inch to 2 feet in size each) throughout the room due to construction taking place at the time of inspection.

26. The Outreach Clinic Back Hallway Electrical Room/Housekeeping Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 4 of 100 doors and hallways clear and unobstructed at all times. This deficient practice would affect approximately 4 residents and 40 staff members within the affected zones. The facility had a capacity of 25 residents and census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Medical Arts Lower Link Exit Pathway by the Maintenance Rooms revealed the corridor was obstructed by chairs and a garbage cart.

2. The 2nd Floor Back Stairwell Door revealed the door was a 15 Second Delayed Egress Door that was not provided with a sign indicating that there was a 15 Second Delay to exit.

3. The 1st Floor Purchasing Hallway revealed storage items within the Hallway that obstructed the width of the corridor.

4. The 2nd Floor In-Patient Area revealed multiple storage items and construction tools within the hallways that obstructs the width of the corridor. This Area was under construction at the time of inspection and had not been approved for occupancy as of the time of the inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations, record review, and interview, the facility failed to maintain the building's emergency lighting units in proper working condition and within proper testing requirements. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 3/21/12, revealed the following:

1. The Medical Clinic West Housekeeping Hallway revealed the emergency lighting unit failed to illuminate when tested.

2. Record review of the Emergency Lighting Testing revealed the emergency lighting unit by Electrical Room 432 was not tested in April or November of 2011 for the 30 second monthly test and failed to be tested for annual 90 minute testing.

3. Record review of the Emergency Lighting Testing revealed the lights in the Main Building 1st Floor failed to receive a 90 minute annual test, the emergency lighting units in the Main Building Ground Floor failed to receive a 90 minute annual test, and the Emergency Lighting Testing Documentation failed to indicate the locations of all emergency lighting units.

4. The Top of the Link Double Door Exit revealed the emergency lighting unit by the door failed to illuminate when tested.

The Assistant Director of Facilities confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed to maintain 2 exit signs in 2 of 20 smoke zones in proper working condition. This deficient practice would affect approximately 15 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observation and interview on 3/21/12, revealed the following:

1. The Top of the Link Double Exit Doors revealed the exit sign failed to illuminate at the time of inspection.

2. The 1st Floor Dietary Director's Office outside of the Director's Office revealed the exit sign failed to illuminate at the time of inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide the proper number of fire drills over a year and failed to properly vary the times and dates of the fire drills that were conducted. This deficient practice would affect all residents within the facility. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Record review and interview on 3/21/12, revealed the following:

1. Record review of the fire drills conducted in the last year revealed the facility failed to provide a fire drill for the 2nd Shift of the 3rd Quarter within the last year.

2. Record review of the fire drill documentation revealed the 3rd Shift Fire Drills conducted in the 1st, 2nd, and 3rd Quarters of the last year were all conducted within the 1100 p.m. hour (1st Quarter-1148 p.m., 2nd Quarter-1100 pm, and 3rd Quarter-1130 p.m.)

3. Record review of the fire drill documentation revealed the 2nd Shift Fire Drills conducted in the 1st, 2nd, and 4th Quarters of the last year were all conducted within the 3:00 p.m. hour (1st Quarter-3:24 p.m., 2nd Quarter-3:00 p.m., and 4th Quarter- 3:31 p.m.)

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, 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 all residents throughout the building. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Fire Alarm Annunciator Panel in the Emergency Room Entrance revealed the Fire Alarm System was in Trouble at the time of inspection. Interview with the Assistant Director of Facilities stated the system was in trouble due to construction.

2. The Emergency Room Corridor outside Room 1 (238) revealed a smoke detector within 3 feet of a air diffuser.

3. The Internal Medicine File Room revealed an single station smoke detector that was no longer in use.

4. The Medical Plaza IT Room revealed a smoke detector installed within 3 feet of an air diffuser.

5. The Laundry Room North Double Doors revealed when the door is held open the door obstructs the fire alarm pull station and the fire alarm horn/strobe devices that were located behind the door.

6. The Locker Room by the Cafeteria revealed the Fire Alarm Horn/Strobe unit was disconnected from the wall.

7. The Medical Clinic West Housekeeping Hallway revealed a smoke detector installed within 3 feet of an air diffuser.

8. The 2nd Floor In-Patient Area revealed the smoke detectors throughout this area were covered by dust covers due to construction within the area. At the time of inspection, this area was under major construction and had not been approved for occupancy as of the date of inspection.

9. The Lab Waiting Room Area revealed a smoke detector installed within 3 feet of an air diffuser.
The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to provide proper sprinkler protection in 6 locations 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 and staff within the facility. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Medical Arts Sprinkler Riser Room revealed the Spare Sprinkler Head Box contained only 5 spare sprinkler heads.

2. The X-Ray Room 2 revealed the X-Ray Machine Ceiling Supports were installed within 2 inches of the sprinkler heads.

3. The Pharmacy Storage Closet revealed the closet was not provided with any sprinkler coverage.

4. The Housekeeping Room by the Cafeteria revealed the room was not provided with any sprinkler coverage.

5. The Men's Locker Room by the Cafeteria revealed the room was not provided with any sprinkler coverage.

6. The Stairwell to the OB Room 101 revealed the Stairwell was not provided with any sprinkler coverage at the 2nd Floor level.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations, record review, and interview, the facility failed to maintain the building's sprinkler system in proper working condition 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 all residents and staff within the facility. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 3/21/12, revealed the following:

1. The Cashier's Room revealed a sprinkler head (1 of 1) missing a cover.

2. The Main Entrance Lobby revealed a sprinkler head with a missing cover.

3. The Area Outside the Rehabilitation Door revealed a sprinkler head (1 of 5) missing a cover.

4. The Rehabilitation New Pool Room revealed the sprinkler heads (4 of 4) were covered due to the area being under construction.

5. The 1st Floor Corridor by the Maintenance Room revealed 2 sprinkler heads missing escutcheon rings.

6. The X-Ray Restroom revealed the sprinkler escutcheon ring was dropped from the sprinkler head (1 of 1).

7. The Nuclear Medicine Room revealed a escutcheon ring missing on a sprinkler head (1 of 2).

8. The 1st Floor directly outside Dietary Director's Office revealed a sprinkler head missing a cover (1 of 18).

9. The Cafeteria Door by the Gift Store revealed a missing cover on a sprinkler head.

10. The Cafeteria by the Entrees revealed a missing cover on the sprinkler head (1 of 8).

11. The Medical Plaza Outreach Clinic Back Hallway Restroom revealed a sprinkler head missing an escutcheon ring (1 of 1).

12. The Medical Plaza Outreach Clinic Restroom by the Electrical/Housekeeping Room revealed a sprinkler head missing an escutcheon ring (1 of 1).

13. The Medical Plaza Back Stairwell revealed a sprinkler head missing an escutcheon ring (1 of 2).

14. The Medical Plaza Sports Medicine Film Storage Room revealed the drop sprinkler heads were dropped below the ceiling tiles.

15. The Medical Plaza Sports Medicine Nurse's Office revealed a sprinkler head missing a cover (1 of 1).

16. The Medical Clinic Storage Room by the Soiled Utility Room revealed a sprinkler head missing an escutcheon ring (1 of 1).

17. The Medical Clinic Storage Room by the Soiled Utility Room revealed storage materials within 18 inches of the sprinkler head.

18. The Medical Clinic Storage Room by Room C6 revealed a missing escutcheon ring on the sprinkler head (1 of 1).

19. The Medical Clinic Exam Room 7 revealed a missing escutcheon ring on the sprinkler head (1 of 1)

20. The Medical Clinic Housekeeping Room by the Records Storage revealed a missing escutcheon ring on the sprinkler head (1 of 1).

21. The Medical Clinic Restroom by the Lab Testing revealed a missing escutcheon ring on the sprinkler head (1 of 1).

22. The 2nd Floor Office 1005 revealed the sprinkler head had dropped below the level of the suspended ceiling.

23. The 2nd Floor In-Patient Area revealed the sprinkler heads throughout the area were covered due to construction of the area. This area was still under major construction and had not been approved for occupancy as of the date of inspection.

24. Record review of the Sprinkler Inspection Documentation from 12/27/11 revealed the "Old Behavior Unit Control Valve does not send a signal to the panel,""the facility needs to re-install inspector's test for patients water flow switch at a new location, several areas under construction," and "low air and tamper switch to MRI can only be read at the MRI panel." Interview with the Assistant Director of Facilities revealed the facility could not provide documentation stating the deficiencies had been corrected.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to provide fire extinguishers in 2 of 20 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 25 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The 2nd Floor In-Patient Entry Area revealed the facility failed to provide any fire extinguishers throughout the area due to it being under major construction at the time of inspection. At the time of inspection, this area was under major construction and had not been given occupancy approved as of the date of inspection.

2. The Medical Plaza IT Room revealed the fire extinguisher was not mounted and was sitting on the floor.

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

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 occupants within the affected area. The facility had a capacity of 25 residents and a census of 4 residents.

Findings include:

Record review and interview on 3/21/12, revealed the Range Hood Inspection Documentation indicated the Range Hood had "No shunt trip to shut off the electricity." Interview with the Assistant Director of Facilities revealed the facility had yet to correct the found deficiency. The Assistant Director of Facilities confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the suspended ceiling tile grid throughout the facility in proper placement. This deficient practice could affect all residents and staff within the affected zones. The facility had a capacity of 25 residents and a census of 4 residents at the time of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Emergency Room Breezeway to the Garage revealed the suspended ceiling tiles were out of place.

2. The 1st Floor Radiology Smoke Barrier revealed the suspended ceiling tiles were out of place due to construction.

3. The 1st Floor X-Ray IT Room revealed there were missing suspended ceiling tiles.

4. The 1st Floor X-Ray Changing Room revealed the suspended ceiling tiles were out of place.

5. The 1st Floor Dietary Director's Office revealed the suspended ceiling tiles were removed due to construction work in this room.

6. The 2nd Floor In-Patient Entry Area revealed the suspended ceiling tiles were not completely installed due to the area being under major construction and had not been approved for occupancy as of the date of inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain proper storage of flammable liquids in 1 room in 1 of 20 smoke zones. This deficient practice would affect approximately 3 residents within the affected zone. The facility had a capacity of 25 residents and a census of 4 residents at the time of inspection.

Findings include:

Observation and interview on 3/21/12, revealed an Liquifed Petroleum (LP) tank and a full 5 gallon gasoline canister were sitting on the floor of the Emergency Room Ambulance Garage Storage Room. The Assistant Director of Facilities confirmed this finding on the date of inspection.

Based on observations and interview, 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 all residents and staff within the affected zones. The facility had a capacity of 25 residents and had a census of 4 residents on the date of inspection.

Findings include:

Observations and interview on 3/21/12, revealed the following:

1. The Operator/Cashier Area revealed a refrigerator, a microwave, and a coffee pot plugged into a plastic surge protector.

2. The Rehabilitation Room New Pool Room revealed multiple open electrical junction boxes due to construction within this room on the date of inspection.

3. The Emergency Room Electrical Room revealed an electrical pull box on a conduit located above Electrical Panel LNE without a cover.

4. The Electrical Room 436 revealed an electrical run box located on the corridor wall did not have a cover on the box.

5. The Electrical Room 437 revealed an electrical run box without a cover located above the East wall door and 2 electrical outlets on the corridor wall without covers.

6. The 2 Hour Fire Resistance Barrier to the Medical Plaza revealed an open electrical junction box located in the center of the Barrier above the suspended ceiling.

7. The Medical Arts Plaza Lower Link Exit Doors revealed an open electrical junction box located above the suspended ceiling.

8. The Medical Plaza Electrical Room revealed the storage of tables and chairs within 3 feet of the electrical panels within the room.

9. The Basement revealed an open electrical junction box on the ceiling lid located in front of the Variable Speed Drive.

10. The 1st Floor Maintenance Mechanical Room revealed storage within 3 feet of the "Normal Power" Electrical Panel.

11. The Maintenance Director's Office revealed exposed electrical wires located on the ceiling deck.

12. The Boiler Room by the Maintenance Garage revealed an open electrical junction box on the ceiling by the Door to the Maintenance Garage.

13. The 2nd Floor Electrical Panels CNIPW located by the Bathing Rooms revealed Electrical Breakers 1, 3, 4, 7, 6, 11, 18, 20, 21, 26, 28, 31, 32, 34, 35, 36, 39, 40, 42, 43, 44, 52, and 54 were not labeled.

14. The 1st Floor Dietary Director's Office revealed multiple electrical junction boxes were not properly covered due to construction.

15. The 1st Floor Pantry revealed storage items within 3 feet of the electrical panels within the room.

16. The 2nd Floor In-Patient Area revealed exposed electrical wiring and electrical junction boxes throughout the area due to major construction in the area. This area was under major construction and had not been approved for occupancy at the time of inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.

The Assistant Director of Facilities confirmed these findings on the date of inspection.