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Based on observation and interview, the facility failed to maintain 1 of approximately 40 doors in 1 of 8 smoke zones in proper working condition. This deficient practice would affect approximately 25 staff members and 8 residents within the affected zone. The facility had a capacity of 25 residents and a census of 8 residents on the date of inspection.

Findings include:

Observation and interview on 5/22/12, revealed the Patient Room 100 Corridor Door failed to close and latch properly into the door frame. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 2 of 6 smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects all residents and staff within the facility. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The Back Door to the Specialty Clinic Smoke Barrier revealed a wire penetration (approximately 1/4 inch in size) located above the suspended ceiling tile.

2. The Smoke Barrier to the Specialty Clinic By Office 132 revealed 2 holes (approximately 1 inch in size each) located above the suspended ceiling tiles.

3. The Smoke Barrier outside the Electrical Closet 281 revealed a conduit sleeve penetration (approximately 6 inches in size) located above the suspended ceiling.

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

Based on observations and interview, the facility failed to maintain 2 of 9 sets of smoke barrier doors in proper working condition. This deficient practice would affect approximately 8 residents and approximately 30 staff members within the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The West Emergency Room Door revealed the door failed to close and latch properly into the door frame with the swing of the door closer when tested.

2. The South Smoke Barrier Doors to the Lobby from the Emergency Department revealed a gap (approximately 1/4 inch in size) between the doors when the doors were in the closed position.

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

Based on observations and staff interview, the facility failed to provide separation of 3 of approximately 20 hazardous areas in 2 of 6 smoke zones 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 8 residents within the affected zones. The facility had a capacity of 25 residents and a census of 8 residents.


Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The IT Closet 173 revealed 2 vertical conduit penetrations (approximately 3 inches in size each).

2. The Medical Records Room revealed 2 conduit sleeve penetrations (approximately 1 inch in size each) located in the East Wall by the Main Entry Desk above the suspended ceiling.

3. The Boiler Room revealed a conduit penetration (approximately 1/2 inch in size) located by the Main Door.

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

Based on observations and interview, the facility failed to maintain 3 exit corridors or doors clear and unobstructed at all times. This deficient practice would affect approximately 8 residents and approximately 30 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The Dining Room revealed a chair obstructing the Serving Area door.

2. The Clean Linen by the Dining Room Door 212 revealed the door was obstructed from opening fully by a cart.

3. The Ambulance Garage North Direct Exit Door revealed was obstructed by a table and chairs.

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 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 facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations, record review, and interview on 5/22/12, revealed the following:

1. The Clinic by Exam Room A9 revealed a smoke detector was installed within 3 feet of an air diffuser.

2. The Medical Records Room revealed a smoke detector was installed within 3 feet of an air diffuser.

3. The Serving Area by the Kitchen revealed a condiment cart was obstructing a Fire Alarm Pull Station.

4. The Demark Room 282 revealed a heat detector had been removed from the ceiling due to construction within the room.

5. The Emergency Room by the Office 337 revealed a smoke detector was installed within 3 feet of an air diffuser.

6. The Physical Therapy Room revealed a smoke detector installed within 3 feet of an air diffuser.

7. Record review of the Fire Alarm Inspection Report revealed the paperwork was not in accordance with the National Fire Protection Association (NFPA) Standard 72. The paperwork provided was a single page.

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 building's sprinkler system in 5 of 6 smoke zones 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 8 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 5/22/12, revealed the following:

1. Record review of the building's Sprinkler System revealed the facility failed to provide a quarterly inspection for the 1st Quarter of the last year.

2. The Ambulance Garage Sprinkler Room revealed the air compressor to the Dry Sprinkler System was not directly hardwired into the building's electrical system.

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

Based on observation and interview, the facility failed to maintain 1 fire extinguisher in 1 of 6 smoke zones in accordance with the National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 1998 edition. This deficient practice would affect approximately 8 residents and approximately 25 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 8 residents on the date of inspection.

Findings include:

Observation and interview on 5/22/12, revealed the fire extinguisher located in the Lab failed to be provided with monthly visual inspections. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observation 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 approximately 4 staff members and 8 residents within the affected zone. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observation and interview on 5/22/12, revealed the facility failed to provide the monthly visual inspections for the building's Range Hood Fire Suppression System located in the Kitchen. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed maintain 1 location in 1 of 6 smoke zones free of unapproved portable heating units. This deficient practice would affect approximately 8 residents within the affected zone. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observation and interview on 5/22/12, revealed a portable space heater that was not provided with an anti-tilt switch located in the Medical Records Room Cubicle Area. The Facility Maintenance Director confirmed this finding 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 8 residents on the date of inspection.

Findings include:

Record review and interview on 5/22/12, revealed the facility failed to provide emergency procedures for the activation, evacuation, and equipment shutdown procedures in the Laboratory. The Facility Maintenance Director confirmed this finding 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 generator in accordance with the National Fire Protection Association (NFPA) Standard 110, 1999 edition. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Record review and interview on 5/22/12, revealed the facility failed to provide proper testing of the Emergency Generator that achieved at least 30% of the Generator Capacity during the monthly testing. 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 3 of 6 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect approximately 8 residents and approximately 50 staff members within the affected zones. The facility had a capacity of 25 residents and had a census of 8 residents on the date of inspection.

Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The Clinic Office by Exam Room A7 revealed a coffee pot plugged into an extension cord.

2. The Smoke Barrier from the Specialty Clinic by Office 132 revealed an open electrical box without a cover located above the suspended ceiling.

3. The Respiratory Therapy Office revealed a coffee pot plugged into a surge protector.

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

Based on observation and interview, the facility failed to maintain 1 of approximately 40 doors in 1 of 8 smoke zones in proper working condition. This deficient practice would affect approximately 25 staff members and 8 residents within the affected zone. The facility had a capacity of 25 residents and a census of 8 residents on the date of inspection.

Findings include:

Observation and interview on 5/22/12, revealed the Patient Room 100 Corridor Door failed to close and latch properly into the door frame. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 2 of 6 smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects all residents and staff within the facility. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The Back Door to the Specialty Clinic Smoke Barrier revealed a wire penetration (approximately 1/4 inch in size) located above the suspended ceiling tile.

2. The Smoke Barrier to the Specialty Clinic By Office 132 revealed 2 holes (approximately 1 inch in size each) located above the suspended ceiling tiles.

3. The Smoke Barrier outside the Electrical Closet 281 revealed a conduit sleeve penetration (approximately 6 inches in size) located above the suspended ceiling.

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

Based on observations and interview, the facility failed to maintain 2 of 9 sets of smoke barrier doors in proper working condition. This deficient practice would affect approximately 8 residents and approximately 30 staff members within the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The West Emergency Room Door revealed the door failed to close and latch properly into the door frame with the swing of the door closer when tested.

2. The South Smoke Barrier Doors to the Lobby from the Emergency Department revealed a gap (approximately 1/4 inch in size) between the doors when the doors were in the closed position.

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

Based on observations and staff interview, the facility failed to provide separation of 3 of approximately 20 hazardous areas in 2 of 6 smoke zones 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 8 residents within the affected zones. The facility had a capacity of 25 residents and a census of 8 residents.


Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The IT Closet 173 revealed 2 vertical conduit penetrations (approximately 3 inches in size each).

2. The Medical Records Room revealed 2 conduit sleeve penetrations (approximately 1 inch in size each) located in the East Wall by the Main Entry Desk above the suspended ceiling.

3. The Boiler Room revealed a conduit penetration (approximately 1/2 inch in size) located by the Main Door.

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

Based on observations and interview, the facility failed to maintain 3 exit corridors or doors clear and unobstructed at all times. This deficient practice would affect approximately 8 residents and approximately 30 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The Dining Room revealed a chair obstructing the Serving Area door.

2. The Clean Linen by the Dining Room Door 212 revealed the door was obstructed from opening fully by a cart.

3. The Ambulance Garage North Direct Exit Door revealed was obstructed by a table and chairs.

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 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 facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations, record review, and interview on 5/22/12, revealed the following:

1. The Clinic by Exam Room A9 revealed a smoke detector was installed within 3 feet of an air diffuser.

2. The Medical Records Room revealed a smoke detector was installed within 3 feet of an air diffuser.

3. The Serving Area by the Kitchen revealed a condiment cart was obstructing a Fire Alarm Pull Station.

4. The Demark Room 282 revealed a heat detector had been removed from the ceiling due to construction within the room.

5. The Emergency Room by the Office 337 revealed a smoke detector was installed within 3 feet of an air diffuser.

6. The Physical Therapy Room revealed a smoke detector installed within 3 feet of an air diffuser.

7. Record review of the Fire Alarm Inspection Report revealed the paperwork was not in accordance with the National Fire Protection Association (NFPA) Standard 72. The paperwork provided was a single page.

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 building's sprinkler system in 5 of 6 smoke zones 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 8 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 5/22/12, revealed the following:

1. Record review of the building's Sprinkler System revealed the facility failed to provide a quarterly inspection for the 1st Quarter of the last year.

2. The Ambulance Garage Sprinkler Room revealed the air compressor to the Dry Sprinkler System was not directly hardwired into the building's electrical system.

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

Based on observation and interview, the facility failed to maintain 1 fire extinguisher in 1 of 6 smoke zones in accordance with the National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 1998 edition. This deficient practice would affect approximately 8 residents and approximately 25 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 8 residents on the date of inspection.

Findings include:

Observation and interview on 5/22/12, revealed the fire extinguisher located in the Lab failed to be provided with monthly visual inspections. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observation 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 approximately 4 staff members and 8 residents within the affected zone. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observation and interview on 5/22/12, revealed the facility failed to provide the monthly visual inspections for the building's Range Hood Fire Suppression System located in the Kitchen. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed maintain 1 location in 1 of 6 smoke zones free of unapproved portable heating units. This deficient practice would affect approximately 8 residents within the affected zone. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observation and interview on 5/22/12, revealed a portable space heater that was not provided with an anti-tilt switch located in the Medical Records Room Cubicle Area. The Facility Maintenance Director confirmed this finding 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 8 residents on the date of inspection.

Findings include:

Record review and interview on 5/22/12, revealed the facility failed to provide emergency procedures for the activation, evacuation, and equipment shutdown procedures in the Laboratory. The Facility Maintenance Director confirmed this finding 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 generator in accordance with the National Fire Protection Association (NFPA) Standard 110, 1999 edition. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Record review and interview on 5/22/12, revealed the facility failed to provide proper testing of the Emergency Generator that achieved at least 30% of the Generator Capacity during the monthly testing. 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 3 of 6 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect approximately 8 residents and approximately 50 staff members within the affected zones. The facility had a capacity of 25 residents and had a census of 8 residents on the date of inspection.

Findings include:

Observations and interview on 5/22/12, revealed the following:

1. The Clinic Office by Exam Room A7 revealed a coffee pot plugged into an extension cord.

2. The Smoke Barrier from the Specialty Clinic by Office 132 revealed an open electrical box without a cover located above the suspended ceiling.

3. The Respiratory Therapy Office revealed a coffee pot plugged into a surge protector.

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