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Based on observation and interview, the facility failed to maintain 1 of approximately 1 of 20 smoke zones in proper working condition. This deficient practice would affect approximately 15 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 and revisit.

Findings include:

Observation and interview on 3/21/12 and revisit on 6/25/12, revealed the MRI Control Room 170 Door the door was wedged open. The Construction Site Manager confirmed this finding on the date of revisit.

Based on observation and interview, the facility failed to maintain 1 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:

Observation and interview on 3/21/12 and revisit on 6/25/12, revealed a gap (approximately 1/2 inch in size) located between the Radiology Smoke Barrier Doors when they were in the closed position. The Construction Site Manager confirmed this finding on the date of revisit.

Based on observations and staff interview, the facility failed to provide proper separation of 3 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 and revisit on 6/25/12, revealed the following:

1. The Maintenance Mechanical Room revealed 2 conduit penetration (approximately 1 inch in size each) located above the "Normal Power" Electrical Panel.

2. The 2nd Floor Storage Room by the Medication Room revealed a center conduit penetration (approximately 1 inch in size).

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

The Construction Site Manager confirmed these findings on the date of revisit.

Based on observation and interview, the facility failed to maintain 1 of approximately 25 hallways clear and unobstructed at all times. This deficient practice would affect approximately 10 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:

Observation and interview on 3/21/12 and revisit on 6/25/12, revealed the 1st Floor Purchasing Hallway storage items within the Hallway that obstructed the width of the corridor. The Construction Site Manager confirmed this finding on the date of revisit.

Based on observation 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:

Observation and interview on 3/21/12 and revisit 6/25/12, revealed when the Laundry Room North Double Doors were held open one door obstructed the fire alarm pull station and the fire alarm horn/strobe devices that were located behind the door. The Construction Site Manager confirmed this finding on the date of revisit.

Based on 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:

Record review and interview on 3/21/12 and revisit on 6/25/12, revealed 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 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 and revisit.

Findings include:

Observations and interview on 3/21/12 and revisit on 6/25/12, 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 1st Floor Maintenance Mechanical Room revealed storage within 3 feet of the "Normal Power" Electrical Panel.

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

The Construction Site Manager confirmed these findings on the date of revisit.