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Based on observation and interview, the facility is not providing doors to the corridor that stay latched tightly within the door frames. This deficient practice would not prevent the spread of smoke, affecting all occupants in one of twelve smoke zones. This facility has a capacity of 25 with a census of 8.

Findings include:

Observation and interview on 02/15/2012 at 11:37 a.m., revealed the door to the Break Room near room #108 failed to close and latch tightly within the door frame due to faulty latching hardware. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that one of nine smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the South Smoke Barrier. This deficient practice affects 4 residents, staff, and visitors in the Acute Care South-Wing. The facility has a capacity of 25 with a census of 8.

Findings include:

Observation and interview on 02/15/2012 at 11:55 a.m., revealed the South-Wing Smoke Barrier contained a one-fourth inch gap around the sprinkler pipe above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of twelve smoke compartments in the building. This could affect 4 residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observation and interview on 02/15/2012 at 11:00 a.m., revealed the facility failed to separate the Elevator Mechanical Room from other compartments. This Mechanical Room contained a 1/4 inch gap around a bundle of wires penetrating the west wall. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 02/15/2012 at 11:42 a.m., revealed the facility failed to separate the Soiled Utility Room from other compartments. This door contained a self closing device that failed to close and positively latch the door. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 8 residents, staff and visitors in this smoke compartment. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observation and interview on 02/15/2012 at 11:40 a.m., revealed the facility failed to maintain the Fire Alarm System in the Corridor near the Physical Therapy Ramp. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 02/15/2012 at 11:40 a.m., revealed the facility failed to maintain the Fire Alarm System in the Pharmacy. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

3. Observation and interview on 02/15/2012 at 12:15 p.m., revealed the facility failed to maintain the Fire Alarm System in the Cardiac Corridor. This corridor contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

4. Observation and interview on 02/15/2012 at 12:34 p.m., revealed the facility failed to maintain the Fire Alarm System near the Nurse Station. The Nurse Station contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

The facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. These items could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 8.

Findings include:

Observation and interview on 02/15/2012 at 11:25 a.m., revealed the facility failed to maintain the sprinkler system in the Lab. One of two quick response sprinkler heads contained lint and dirt covering the entire head. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all the residents and staff in the 2 rooms. This facility has a capacity of 25 and a census of 8.

Findings include:

1. Observation and interview of the mini blinds in the Kidney Dialysis Room on 02/15/2012 at 12:30 p.m., revealed the eleven sets of vinyl mini blinds 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 at the time of the survey process.

2. Observation and interview of the mini blinds in the Cardiac Stress Test Room on 02/15/2012 at 12:32 p.m., revealed the two sets of vinyl mini blinds 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 at the time of the survey process.

Based on observation and interview, 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 all Staff in this room at risk in the event of a fire. The facility had a capacity of 25 and a census of 8.

Findings Include:

1. Observation and interview on 02/15/2012 at 10:50 a.m., revealed the facility failed to maintain the electrical system in the Maintenance Room. This room contained an open junction box with exposed electrical. The Maintenance Director verified this observation at the time of the survey process and covered the box with a metal box cover plate.

2. Observation and interview on 02/15/2012 at 11:18 a.m., revealed the facility failed to maintain the electrical system in the Fire Pump Room. This room contained three open junction boxes with exposed electrical. The Maintenance Director verified this observation at the time of the survey process.

3. Observation and interview on 02/15/2012 at 11:20 a.m., revealed the facility failed to maintain the electrical system in the Mechanical Room. This room contained a six inch by six inch open junction box with exposed electrical. The Maintenance Director verified this observation at the time of the survey process.

4. Observation and interview on 02/15/2012 at 11:35 a.m., revealed the facility failed to maintain the electrical system in the I. T. Room. This room contained an open electrical junction box with exposed electrical wiring along the ceiling. The Maintenance Director verified this observation at the time of the survey process.