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Based on observations and interview, the facility failed to maintain the 2 hour fire resistance wall properly maintained and free of penetrations. This deficient practice would affect all staff members and approximately 3 residents within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor 2 Hour Fire Wall to the South Stairwell revealed a pipe penetration (approximately 1/2 inch in size) and a conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling.

2. The 1st Floor 2 Hour Fire Wall to the Elevator Lobby revealed a copper pipe penetration (approximately 1 inch in size), 3 large pipe penetrations (approximately 3 inches in size each), 2 conduit penetrations (approximately 1 inch in size each), and 2 holes (approximately 1 inch in size each) located above the suspended ceiling tiles.

3. The Main Floor 2 Hour Fire Wall in the Main Hallway revealed a center conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling tile.

4. The Main Floor 2 Hour Fire Wall by the Cafeteria revealed 3 conduit penetrations (approximately 1 to 3 inches in size each) and a wire bundle penetration (approximately 3 inches in size) located above the suspended ceiling tile.

5. The 2 Hour Fire Wall by the Specialty Clinic revealed that the Corridor Door failed to close and latch properly into the door frame with the swing of the door closer.

6. The 2 Hour Fire Doors by the Patient Room 4 revealed the doors failed to close and latch properly into the door frame with the swing of the door closer when tested.

7. The 2 Hour Fire Doors by the Laboratory Entrance revealed the doors failed to close and latch properly into the door frame with the swing of the door closers when tested.

8. The 2 Hour Fire Doors in the Short Corridor by Radiology revealed the doors failed to close and latch properly into the door frame with the swing of the door closers when tested.

9. The 2 Hour Fire Doors by the Elevator on the 2nd Floor revealed one of the doors was rubbing on the carpet and failed to close and latch properly into the door frame with the swing of the door closer.

The Facility Maintenance Director and the Facility Staff Member A confirmed these findings on the date of inspection.

Based on observation and staff interview, it was determined the facility was a one-story building and consisted of non-protected combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with one-hour fire rated materials. This deficient practice affects approximately 1 of 12 smoke zones and approximately 2 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 11 residents at the time of inspection.

Findings include:

Observation and interview on 3/7/13, revealed a vertical hole (approximately 2 inches in size) located in the ceiling lid of the Chief Clinic Officer's Office. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 8 of approximately 45 corridor doors in 6 of 12 smoke zones in proper working condition. This deficient practice would affect approximately 11 residents within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor West Hall Sleep Tech Room revealed the door was warped and revealed a gap (approximately 1 inch in size) located between the door and the door frame.

2. The 2nd Floor West Hall Sleep/Storage Room revealed a kick-down device ws installed on the door and kept the door from closing in to the door frame properly.

3. The 2nd Floor Employees Shower Room revealed a louver within the door that kept the hallway from being smoke tight.

4. The Same Day Surgery Doctor's Dictation Room revealed the corridor door failed to close and latch properly into the door frame when tested.

5. The Main Floor Patient Room 9 revealed the corridor door failed to close and latch properly into the door frame when tested.

6. The 2nd Floor Old Treatment Room revealed the door was missing any latching hardware.

7. The 1st Floor Same Day Surgery Men's Changing Room revealed the door failed to close and latch properly into the door frame when tested.

8. The 1st Floor Patient Room 8 revealed the Corridor Door failed to close and latch properly into the door frame when tested.

The Facility Maintenance Director and the Facility Maintenance Staff Member A 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 3 locations within the facility. This deficient practice could affect approximately 11 residents and all staff within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor North Stairwell Physical Therapy Exit revealed the door failed to close and latch properly into the door frame with the swing of the door closer when tested.

2. The Stairwell Doors by the Director of Human Services Office revealed both doors failed to close and latch properly into the door frame with the swing of the door closers when tested.

3. The Main Level Stairwell Door by the Fire Alarm Control Panel revealed the door failed to close and latch properly into the door frame with the swing of the door closer. This door also revealed it was missing latching hardware.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of 7 of approximately 15 hazardous areas in 5 of 12 smoke barriers 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 11 residents within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor Nitrogen Storage Room revealed a pipe penetration (approximately 1/2 inch in size) located in the East Wall.

2. The 1st Floor Same Day Surgery Linen/Laundry Room revealed a kick-down device installed on the corridor door that kept the door from closing and latching with the swing of the door closer.

3. The 1st Floor Interstice Mechanical Room revealed a pipe penetration (approximately 3 inches in size), a conduit sleeve penetration (approximately 2 inches in size), and 2 pipe penetrations (approximately 2 inches in size) located above the corridor door.

4. The Main Floor Janitorial Room revealed the door was not provided with a self-closing device. This room also revealed a wire penetration (approximately 2 inches in size), a pipe penetration (approximately 2 inches in size), and multiple vertical penetrations (approximately 1 to 3 inches in size each) located in the walls and the ceiling lid.

5. The Main Floor Electrical Room by Patient Room 3 revealed the room was not provided with a self-closing device on the Corridor Door.

6. The Old Boiler Room/Sprinkler Riser Room revealed the door failed to close and latch into the door frame with the swing of the door. This room also revealed 2 insulated pipe penetrations (approximately 1/2 inch in size each) and a sprinkler pipe penetration (approximately 1/2 inch in size) located in the Corridor Walls.

7. The Print Room Storage Room revealed a pipe penetration (approximately 3 inches in size), a pipe penetration (approximately 2 inches in size), an open pipe penetration (approximately 1/2 inch in size), 3 holes (approximately 1/2 inch in size each), a pipe penetration (approximately 1/4 inch in size), a conduit penetration (approximately 1/4 inch in size), and a hole (approximately 1 inch in size) located in the Corridor Walls.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

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 11 residents on the date of inspection.

Findings include:

Record review and interview on 3/7/13, revealed the facility failed to provide the 90 minute annual testing for the building's Emergency Lighting Units in 2012. The Facility Maintenance Director confirmed this finding 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 within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The Main Level Door located outside the Laundry Room revealed the door failed to release upon activation of the Fire Alarm System.

2. The Main Floor Main Janitorial Room revealed a paint-like substance on the heat detector.

3. The 2nd Floor West Hall Administrative Office at the end of the hall revealed a smoke detector installed within 3 feet of an air diffuser.

4. The 2nd Floor Conference Room #12 revealed a smoke detector installed within 3 feet of an air diffuser.

5. The 1st Floor Same Day Surgery Lobby revealed a smoke detector installed within 3 feet of an air diffuser.

6. The 1st Floor Fire Alarm Control Panel failed to provide the location of the Fire Alarm Control Panel Breaker.

7. The 1st Floor CT Room revealed 2 smoke detectors installed within 3 feet of an air diffuser.

8. The 1st Floor CT Room revealed a dust cover covering the smoke detector.

9. The 1st Floor Fire Alarm Control Panel Electrical Breaker revealed the breaker was not properly secured.

10. The Corridor outside the Cafeteria revealed a smoke detector installed within 3 feet of an air diffuser.

11. The Short Corridor by Radiology revealed a smoke detector installed within 3 feet of an air diffuser.

12. The Environmental Services Room A09 revealed a smoke detector installed within 3 feet of an air diffuser.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide proper sprinkler protection in 1 location in 1 of 12 smoke zones 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 approximately 1 staff member within the facility. The facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings include:

Observation and interview on 3/7/13, revealed the Chief Clinic Officer's Office Closet was not provided with sprinkler protection. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations, record review, and interview, 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 all residents within the facility. The facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 3/7/13, revealed the following:

1. The 1st Floor Elevator Lobby revealed a paint/mud like substance on the sprinkler heads (2 of 3).

2. Record review of the Facility's Sprinkler System Report revealed the facility failed to provide the sprinkler inspection reports for the last year.

3. The 1st Floor Same Day Surgery revealed a missing escutcheon ring to the sprinkler head located in the Corridor by the Restroom.

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

Based on observations, 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 residents and staff members within the facility. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations, record review, and interview on 3/7/13, revealed the following:

1. The Kitchen Range Hood Suppression System revealed the facility failed to provide the monthly visual inspections for the system.

2. Record review revealed the facility failed to provide any testing for the Suppression System in the Range Hood in the Kitchen in 2012. The Facility was unable to provide any documentation.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to properly maintain the suspended ceiling tile grid in 2 of 12 smoke zones within the building. This deficient practice would affect approximately 3 residents within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor West Hall Sleep/Storage Room revealed several missing suspended ceiling tiles.

2. The Dirty Linen Room 260 revealed several missing suspended ceiling tiles.

The Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide proper emergency procedures for the laboratory in accordance with Section 18.3.2.2 of the Life Safety Code 2000 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 11 residents on the date of inspection.

Findings include:

Record review and interview on 3/7/13, revealed the Laboratory failed to provide any records or policies indicating procedures to be taken in the event of a fire within the Laboratory. The Laboratory Director stated they follow the usual procedures of the hospital. The Facility Maintenance Director 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 approximately 11 residents within the affected zones. The facility had a capacity of 25 residents and had a census of 11 residents on the date of inspection.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 1st Floor Mezzanine Mechanical Room revealed the Electrical Panel NL20 Electrical Breakers 2, 4, 5, and 7-16 revealed these breakers were not labeled.

2. The Mezzanine Mechanical Room revealed an open electrical junction box located by the AHU #2.

3. The IT Hub revealed an open electrical outlet box.

4. The Chief Clinic Officer's Office revealed an open junction box located by the wall unit.

5. The Gift Shop revealed an electrical extension cord to a surge protector.

6. The Medical Records Front Desk revealed a fan plugged into a surge protector.

7. The 1st Floor 2 Hour Barrier by the Elevator revealed the Electromagnetic Devices to the doors were missing covers.

8. The 1st Floor by the 2 Hour Fire Wal revealed open electrical junction box without a cover and the box was falling out of the wall.

9. The Payroll Office revealed a surge protector plugged into another surge protector.

10. The Electrical Room in the Patient Care Wing revealed an extension cord to the IT Modem.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain the 2 hour fire resistance wall properly maintained and free of penetrations. This deficient practice would affect all staff members and approximately 3 residents within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor 2 Hour Fire Wall to the South Stairwell revealed a pipe penetration (approximately 1/2 inch in size) and a conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling.

2. The 1st Floor 2 Hour Fire Wall to the Elevator Lobby revealed a copper pipe penetration (approximately 1 inch in size), 3 large pipe penetrations (approximately 3 inches in size each), 2 conduit penetrations (approximately 1 inch in size each), and 2 holes (approximately 1 inch in size each) located above the suspended ceiling tiles.

3. The Main Floor 2 Hour Fire Wall in the Main Hallway revealed a center conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling tile.

4. The Main Floor 2 Hour Fire Wall by the Cafeteria revealed 3 conduit penetrations (approximately 1 to 3 inches in size each) and a wire bundle penetration (approximately 3 inches in size) located above the suspended ceiling tile.

5. The 2 Hour Fire Wall by the Specialty Clinic revealed that the Corridor Door failed to close and latch properly into the door frame with the swing of the door closer.

6. The 2 Hour Fire Doors by the Patient Room 4 revealed the doors failed to close and latch properly into the door frame with the swing of the door closer when tested.

7. The 2 Hour Fire Doors by the Laboratory Entrance revealed the doors failed to close and latch properly into the door frame with the swing of the door closers when tested.

8. The 2 Hour Fire Doors in the Short Corridor by Radiology revealed the doors failed to close and latch properly into the door frame with the swing of the door closers when tested.

9. The 2 Hour Fire Doors by the Elevator on the 2nd Floor revealed one of the doors was rubbing on the carpet and failed to close and latch properly into the door frame with the swing of the door closer.

The Facility Maintenance Director and the Facility Staff Member A confirmed these findings on the date of inspection.

Based on observation and staff interview, it was determined the facility was a one-story building and consisted of non-protected combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with one-hour fire rated materials. This deficient practice affects approximately 1 of 12 smoke zones and approximately 2 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 11 residents at the time of inspection.

Findings include:

Observation and interview on 3/7/13, revealed a vertical hole (approximately 2 inches in size) located in the ceiling lid of the Chief Clinic Officer's Office. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 8 of approximately 45 corridor doors in 6 of 12 smoke zones in proper working condition. This deficient practice would affect approximately 11 residents within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor West Hall Sleep Tech Room revealed the door was warped and revealed a gap (approximately 1 inch in size) located between the door and the door frame.

2. The 2nd Floor West Hall Sleep/Storage Room revealed a kick-down device ws installed on the door and kept the door from closing in to the door frame properly.

3. The 2nd Floor Employees Shower Room revealed a louver within the door that kept the hallway from being smoke tight.

4. The Same Day Surgery Doctor's Dictation Room revealed the corridor door failed to close and latch properly into the door frame when tested.

5. The Main Floor Patient Room 9 revealed the corridor door failed to close and latch properly into the door frame when tested.

6. The 2nd Floor Old Treatment Room revealed the door was missing any latching hardware.

7. The 1st Floor Same Day Surgery Men's Changing Room revealed the door failed to close and latch properly into the door frame when tested.

8. The 1st Floor Patient Room 8 revealed the Corridor Door failed to close and latch properly into the door frame when tested.

The Facility Maintenance Director and the Facility Maintenance Staff Member A 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 3 locations within the facility. This deficient practice could affect approximately 11 residents and all staff within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor North Stairwell Physical Therapy Exit revealed the door failed to close and latch properly into the door frame with the swing of the door closer when tested.

2. The Stairwell Doors by the Director of Human Services Office revealed both doors failed to close and latch properly into the door frame with the swing of the door closers when tested.

3. The Main Level Stairwell Door by the Fire Alarm Control Panel revealed the door failed to close and latch properly into the door frame with the swing of the door closer. This door also revealed it was missing latching hardware.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of 7 of approximately 15 hazardous areas in 5 of 12 smoke barriers 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 11 residents within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor Nitrogen Storage Room revealed a pipe penetration (approximately 1/2 inch in size) located in the East Wall.

2. The 1st Floor Same Day Surgery Linen/Laundry Room revealed a kick-down device installed on the corridor door that kept the door from closing and latching with the swing of the door closer.

3. The 1st Floor Interstice Mechanical Room revealed a pipe penetration (approximately 3 inches in size), a conduit sleeve penetration (approximately 2 inches in size), and 2 pipe penetrations (approximately 2 inches in size) located above the corridor door.

4. The Main Floor Janitorial Room revealed the door was not provided with a self-closing device. This room also revealed a wire penetration (approximately 2 inches in size), a pipe penetration (approximately 2 inches in size), and multiple vertical penetrations (approximately 1 to 3 inches in size each) located in the walls and the ceiling lid.

5. The Main Floor Electrical Room by Patient Room 3 revealed the room was not provided with a self-closing device on the Corridor Door.

6. The Old Boiler Room/Sprinkler Riser Room revealed the door failed to close and latch into the door frame with the swing of the door. This room also revealed 2 insulated pipe penetrations (approximately 1/2 inch in size each) and a sprinkler pipe penetration (approximately 1/2 inch in size) located in the Corridor Walls.

7. The Print Room Storage Room revealed a pipe penetration (approximately 3 inches in size), a pipe penetration (approximately 2 inches in size), an open pipe penetration (approximately 1/2 inch in size), 3 holes (approximately 1/2 inch in size each), a pipe penetration (approximately 1/4 inch in size), a conduit penetration (approximately 1/4 inch in size), and a hole (approximately 1 inch in size) located in the Corridor Walls.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

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 11 residents on the date of inspection.

Findings include:

Record review and interview on 3/7/13, revealed the facility failed to provide the 90 minute annual testing for the building's Emergency Lighting Units in 2012. The Facility Maintenance Director confirmed this finding 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 within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The Main Level Door located outside the Laundry Room revealed the door failed to release upon activation of the Fire Alarm System.

2. The Main Floor Main Janitorial Room revealed a paint-like substance on the heat detector.

3. The 2nd Floor West Hall Administrative Office at the end of the hall revealed a smoke detector installed within 3 feet of an air diffuser.

4. The 2nd Floor Conference Room #12 revealed a smoke detector installed within 3 feet of an air diffuser.

5. The 1st Floor Same Day Surgery Lobby revealed a smoke detector installed within 3 feet of an air diffuser.

6. The 1st Floor Fire Alarm Control Panel failed to provide the location of the Fire Alarm Control Panel Breaker.

7. The 1st Floor CT Room revealed 2 smoke detectors installed within 3 feet of an air diffuser.

8. The 1st Floor CT Room revealed a dust cover covering the smoke detector.

9. The 1st Floor Fire Alarm Control Panel Electrical Breaker revealed the breaker was not properly secured.

10. The Corridor outside the Cafeteria revealed a smoke detector installed within 3 feet of an air diffuser.

11. The Short Corridor by Radiology revealed a smoke detector installed within 3 feet of an air diffuser.

12. The Environmental Services Room A09 revealed a smoke detector installed within 3 feet of an air diffuser.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide proper sprinkler protection in 1 location in 1 of 12 smoke zones 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 approximately 1 staff member within the facility. The facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings include:

Observation and interview on 3/7/13, revealed the Chief Clinic Officer's Office Closet was not provided with sprinkler protection. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations, record review, and interview, 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 all residents within the facility. The facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 3/7/13, revealed the following:

1. The 1st Floor Elevator Lobby revealed a paint/mud like substance on the sprinkler heads (2 of 3).

2. Record review of the Facility's Sprinkler System Report revealed the facility failed to provide the sprinkler inspection reports for the last year.

3. The 1st Floor Same Day Surgery revealed a missing escutcheon ring to the sprinkler head located in the Corridor by the Restroom.

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

Based on observations, 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 residents and staff members within the facility. The facility had a capacity of 25 residents and a census of 11 residents.

Findings include:

Observations, record review, and interview on 3/7/13, revealed the following:

1. The Kitchen Range Hood Suppression System revealed the facility failed to provide the monthly visual inspections for the system.

2. Record review revealed the facility failed to provide any testing for the Suppression System in the Range Hood in the Kitchen in 2012. The Facility was unable to provide any documentation.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to properly maintain the suspended ceiling tile grid in 2 of 12 smoke zones within the building. This deficient practice would affect approximately 3 residents within the affected zones. The facility had a capacity of 25 residents and a census of 11 residents on the date of inspection.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 2nd Floor West Hall Sleep/Storage Room revealed several missing suspended ceiling tiles.

2. The Dirty Linen Room 260 revealed several missing suspended ceiling tiles.

The Facility Maintenance Staff Member A confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide proper emergency procedures for the laboratory in accordance with Section 18.3.2.2 of the Life Safety Code 2000 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 11 residents on the date of inspection.

Findings include:

Record review and interview on 3/7/13, revealed the Laboratory failed to provide any records or policies indicating procedures to be taken in the event of a fire within the Laboratory. The Laboratory Director stated they follow the usual procedures of the hospital. The Facility Maintenance Director 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 approximately 11 residents within the affected zones. The facility had a capacity of 25 residents and had a census of 11 residents on the date of inspection.

Findings include:

Observations and interview on 3/7/13, revealed the following:

1. The 1st Floor Mezzanine Mechanical Room revealed the Electrical Panel NL20 Electrical Breakers 2, 4, 5, and 7-16 revealed these breakers were not labeled.

2. The Mezzanine Mechanical Room revealed an open electrical junction box located by the AHU #2.

3. The IT Hub revealed an open electrical outlet box.

4. The Chief Clinic Officer's Office revealed an open junction box located by the wall unit.

5. The Gift Shop revealed an electrical extension cord to a surge protector.

6. The Medical Records Front Desk revealed a fan plugged into a surge protector.

7. The 1st Floor 2 Hour Barrier by the Elevator revealed the Electromagnetic Devices to the doors were missing covers.

8. The 1st Floor by the 2 Hour Fire Wal revealed open electrical junction box without a cover and the box was falling out of the wall.

9. The Payroll Office revealed a surge protector plugged into another surge protector.

10. The Electrical Room in the Patient Care Wing revealed an extension cord to the IT Modem.

The Facility Maintenance Director and the Facility Maintenance Staff Member A confirmed these findings on the date of inspection.