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Based on observation, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects two of six smoke compartments in the building. This could affect approximately 11 residents, clinic patients, visitors and staff members. The facility has a capacity of 25 and a census of 3.

Findings include:

1. Observations on 07/21/10 at 09:50 a.m., revealed the facility failed to separate the Steam Boiler Room from other compartments. This room contained a 3/4 inch gap around a 1/2 inch pipe penetrating the north east wall.

2. Observations on 07/21/10 at 09:52 a.m., revealed the facility failed to separate the Steam Boiler Room from other compartments. This room contained a 1/2 inch gap around a 1/2 pipe penetrating the ceiling.

3. Observations on 07/21/10 at 10:05 a.m., revealed the facility failed to separate the North clinic Storage Room from other compartments. This Medical Records room contained combustible storage, was over eighty square feet and did not have a self closing device.

4. Observations on 07/21/10 at 10:22 a.m., revealed the facility failed to separate the hot water Boiler Room from other compartments. This room contained a three inch hole with a 3/4 gap around a two inch pipe penetrating the corridor along the west wall.

5. Observations on 07/21/10 at 10:20 a.m., revealed the facility failed to separate the hot water Boiler Room from other compartments. This room contained a 1/4 inch gap with a 3/4 gap around a bundle of red wires pipe penetrating the corridor along the west wall.

6. Observations on 7/21/10 at 10:10 a.m., revealed the facility failed to separate the North Clinic Elevator Equipment Room from other compartments. This Elevator equipment room door contained an open louver that opened up into the clinic.

7. Observations on 7/21/10 at 10:27 a.m., revealed the facility failed to separate the West Elevator Equipment Room from other compartments. This Elevator equipment room door contained an open louver that opened up into the Physical Therapy Room.

The Maintenance Director verified these observations.

Based on observation, the facility is not providing unobstructed corridors that provide a clear path of egress for one of six smoke zones. This deficient practice could effect 10 patients, staff and visitors. The facility has a capacity of 25 with a census of 3.

Findings include:

Observations on 07/21/10 at 10:24 a.m., revealed the facility failed to maintain the corridor in the East Clinic. This corridor leading to the west exit door contained numerous boxes and restricted the corridor width to approximately 3 feet. The Maintenance Director verified this observation. According to the facility layout, this was a required exit.

Based on record review, the facility failed to document the emergency egress lighting annually. This deficient practice affects six of six smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 3.

Findings include:

Record review of the facility's maintenance records on 07/21/10 at 9:40 a.m., revealed that there was no documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff, the lights were tested monthly, but there was no documentation to show that an annual test was completed for 90 minutes under load.

Based on observation and record review, the facility failed to maintain and test a complete automatic sprinkler system. This deficient practice would effect all residents, staff and visitors in six of six smoke compartments. The facility has a capacity of 25 and a census of 3.

Findings include:

1. Record review of the facilities fire safety components on 07/21/10 at 09:35 a.m., revealed the facility failed to maintain the facility's sprinkler system. The facility could not provide documentation for any quarterly testing of the sprinkler system. The Maintenance Director stated they were only having an annual inspection performed on the sprinkler system.

2. Observations on 07/21/10 at 10:02 a.m., revealed the facility failed to maintain the sprinkler system in the Kitchen. Two of nine sprinkler heads contained lint and dust covering the entire sprinkler head. The Maintenance Director verified these observations.

Based on observation and record review the facility could not provide documentation that the window blinds were flame resistant. The facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. This has the potential of affecting all patients, staff and visitors in this room. This facility has a capacity of 25 and a census of 3.

Findings include:

Observations and record review the mini blinds in the Physical Therapy Room on 07/21/10 at 10:28 a.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Maintenance Director verified this observation.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing Staff, patients and visitors of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 3.

Findings Include:

Observations on 07/21/10 at 10:26 a.m., revealed the facility failed to maintain the electrical system in the West Elevator Room. This room contained an open blank with exposed electrical wiring in the Electrical outlet along the west wall. The Maintenance Director verified these observations.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects two of six smoke compartments in the building. This could affect approximately 11 residents, clinic patients, visitors and staff members. The facility has a capacity of 25 and a census of 3.

Findings include:

1. Observations on 07/21/10 at 09:50 a.m., revealed the facility failed to separate the Steam Boiler Room from other compartments. This room contained a 3/4 inch gap around a 1/2 inch pipe penetrating the north east wall.

2. Observations on 07/21/10 at 09:52 a.m., revealed the facility failed to separate the Steam Boiler Room from other compartments. This room contained a 1/2 inch gap around a 1/2 pipe penetrating the ceiling.

3. Observations on 07/21/10 at 10:05 a.m., revealed the facility failed to separate the North clinic Storage Room from other compartments. This Medical Records room contained combustible storage, was over eighty square feet and did not have a self closing device.

4. Observations on 07/21/10 at 10:22 a.m., revealed the facility failed to separate the hot water Boiler Room from other compartments. This room contained a three inch hole with a 3/4 gap around a two inch pipe penetrating the corridor along the west wall.

5. Observations on 07/21/10 at 10:20 a.m., revealed the facility failed to separate the hot water Boiler Room from other compartments. This room contained a 1/4 inch gap with a 3/4 gap around a bundle of red wires pipe penetrating the corridor along the west wall.

6. Observations on 7/21/10 at 10:10 a.m., revealed the facility failed to separate the North Clinic Elevator Equipment Room from other compartments. This Elevator equipment room door contained an open louver that opened up into the clinic.

7. Observations on 7/21/10 at 10:27 a.m., revealed the facility failed to separate the West Elevator Equipment Room from other compartments. This Elevator equipment room door contained an open louver that opened up into the Physical Therapy Room.

The Maintenance Director verified these observations.

Based on observation, the facility is not providing unobstructed corridors that provide a clear path of egress for one of six smoke zones. This deficient practice could effect 10 patients, staff and visitors. The facility has a capacity of 25 with a census of 3.

Findings include:

Observations on 07/21/10 at 10:24 a.m., revealed the facility failed to maintain the corridor in the East Clinic. This corridor leading to the west exit door contained numerous boxes and restricted the corridor width to approximately 3 feet. The Maintenance Director verified this observation. According to the facility layout, this was a required exit.

Based on record review, the facility failed to document the emergency egress lighting annually. This deficient practice affects six of six smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 3.

Findings include:

Record review of the facility's maintenance records on 07/21/10 at 9:40 a.m., revealed that there was no documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff, the lights were tested monthly, but there was no documentation to show that an annual test was completed for 90 minutes under load.

Based on observation and record review, the facility failed to maintain and test a complete automatic sprinkler system. This deficient practice would effect all residents, staff and visitors in six of six smoke compartments. The facility has a capacity of 25 and a census of 3.

Findings include:

1. Record review of the facilities fire safety components on 07/21/10 at 09:35 a.m., revealed the facility failed to maintain the facility's sprinkler system. The facility could not provide documentation for any quarterly testing of the sprinkler system. The Maintenance Director stated they were only having an annual inspection performed on the sprinkler system.

2. Observations on 07/21/10 at 10:02 a.m., revealed the facility failed to maintain the sprinkler system in the Kitchen. Two of nine sprinkler heads contained lint and dust covering the entire sprinkler head. The Maintenance Director verified these observations.

Based on observation and record review the facility could not provide documentation that the window blinds were flame resistant. The facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. This has the potential of affecting all patients, staff and visitors in this room. This facility has a capacity of 25 and a census of 3.

Findings include:

Observations and record review the mini blinds in the Physical Therapy Room on 07/21/10 at 10:28 a.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Maintenance Director verified this observation.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing Staff, patients and visitors of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 3.

Findings Include:

Observations on 07/21/10 at 10:26 a.m., revealed the facility failed to maintain the electrical system in the West Elevator Room. This room contained an open blank with exposed electrical wiring in the Electrical outlet along the west wall. The Maintenance Director verified these observations.