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Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of six smoke zones in the building. These areas could affect approximately 21 residents and staff members. The facility has 21 certified beds and at the time of the survey the census was 9.

Findings include:

1. Observation and interview on 06/03/14 at approximately 10:20 a.m., revealed the corridor door to the Gift Shop was held open with a door wedge.

2. Observation and interview on 06/03/14 at approximately 11:35 a.m., revealed that in the Ellsworth Family Medical Clinic the stairway door was held open with a kick down device. The basement contained medical record combustible storage.

Maintenance Staff (A) verified these observations.

Based on observation and interview the facility failed to maintain the exit discharge lighting so that the path from the facility to the parking lot would not be in darkness. This deficient practice affects all staff and residents. This facility has a capacity of 21 and a census of 9 residents.
Findings include:
Observation and interview on 06/03/14 at 9:30 a.m., revealed the two battery operated emergency exit lights in the Main Electrical Transfer room failed to operate when tested.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility census is 21 with a capacity of 9.

Findings include:

In the Ackley Clinic the record review and interview on 06-03-14, the facility was unable to produce documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacturer.

Maintenance Staff (A) verified this documentation.

Based upon observation and interview, the facility failed to properly install alcohol based hand rub (ABHR) dispensers. This has the potential of affecting staff , visitors and residents. This facility has a capacity of 21 with a census of 9.

Findings include:

Observation and interview on 06/03/14 at approximately 11:00 a.m., there was an alcohol based hand rub dispenser located on the south wall next to the West Employee Entrance in the Ellsworth Family Medical Clinic. The dispenser was located directly over a light switch.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of six smoke zones in the building. These areas could affect approximately 21 residents and staff members. The facility has 21 certified beds and at the time of the survey the census was 9.

Findings include:

1. Observation and interview on 06/03/14 at approximately 10:20 a.m., revealed the corridor door to the Gift Shop was held open with a door wedge.

2. Observation and interview on 06/03/14 at approximately 11:35 a.m., revealed that in the Ellsworth Family Medical Clinic the stairway door was held open with a kick down device. The basement contained medical record combustible storage.

Maintenance Staff (A) verified these observations.

Based on observation and interview the facility failed to maintain the exit discharge lighting so that the path from the facility to the parking lot would not be in darkness. This deficient practice affects all staff and residents. This facility has a capacity of 21 and a census of 9 residents.
Findings include:
Observation and interview on 06/03/14 at 9:30 a.m., revealed the two battery operated emergency exit lights in the Main Electrical Transfer room failed to operate when tested.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility census is 21 with a capacity of 9.

Findings include:

In the Ackley Clinic the record review and interview on 06-03-14, the facility was unable to produce documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacturer.

Maintenance Staff (A) verified this documentation.