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Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of nineteen smoke zones in the building. These areas could affect staff members. The facility has 25 certified beds and at the time of the survey the census was 15.

Findings include:

During observation of the combustible storage room in the Kitchen on 07-15-11 at approximately 1:00 p.m., revealed that the corridor door #2436 to the Kitchen Storage Room which is used for combustible storage was not provided with a self closer on the door.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the facility failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This item could effect the operation of the heads by obstructing spray patterns. This deficient practice affects resident, staff and visitors. This facility with a capacity of 25 and a census of 15.

Findings include:

1. Observation on 7-15-11, revealed that the Blood Draw room in the Lab had three privacy curtains installed with a very fine mesh of one-quarter inch at the top of the curtain which would obstruct the spray patterns. The Life Safety Code requires that the mesh size is no less than 1/2 inch in size as measured on the diagonal.

2. Observation on 7-15-11 at approximately 1:28 p.m., revealed that the Radiology Changing rooms contained partial walls that were approximately 7 inches from the ceiling. The corridor out side of the rooms was sprinkled but the Changing rooms were not equipped with sprinkler protection.

Maintenance Staff (A) verified these observations.

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 the Staff of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 15 at the time of the survey.

Findings Include:

Observations and interview on 07-15-11 at approximately 1:07 p.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter electrical outlet in the west wall of the Kitchen Dish Wash room next to the sink.

Maintenance Staff (A) verified this observation.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects one of nineteen smoke zones in the building. These areas could affect staff members. The facility has 25 certified beds and at the time of the survey the census was 15.

Findings include:

During observation of the combustible storage room in the Kitchen on 07-15-11 at approximately 1:00 p.m., revealed that the corridor door #2436 to the Kitchen Storage Room which is used for combustible storage was not provided with a self closer on the door.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the facility failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This item could effect the operation of the heads by obstructing spray patterns. This deficient practice affects resident, staff and visitors. This facility with a capacity of 25 and a census of 15.

Findings include:

1. Observation on 7-15-11, revealed that the Blood Draw room in the Lab had three privacy curtains installed with a very fine mesh of one-quarter inch at the top of the curtain which would obstruct the spray patterns. The Life Safety Code requires that the mesh size is no less than 1/2 inch in size as measured on the diagonal.

2. Observation on 7-15-11 at approximately 1:28 p.m., revealed that the Radiology Changing rooms contained partial walls that were approximately 7 inches from the ceiling. The corridor out side of the rooms was sprinkled but the Changing rooms were not equipped with sprinkler protection.

Maintenance Staff (A) verified these observations.

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 the Staff of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 15 at the time of the survey.

Findings Include:

Observations and interview on 07-15-11 at approximately 1:07 p.m., revealed the facility failed to provide a Ground Fault Circuit Interrupter electrical outlet in the west wall of the Kitchen Dish Wash room next to the sink.

Maintenance Staff (A) verified this observation.