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Based on observation, the facility failed to maintain the doors within a two-hour fire wall to close and latch properly. This deficient practice would not prevent the spread of fire and smoke to another zone. This facility has a capacity of 25 and a census of 19.

Findings include:

Observations on 9/14/10, revealed the 90 minute door in the two-hour fire wall on the ground level to the stairway for the employee entrance near Central Supply did not latch properly when tested.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants as the doors would not prevent the spread of fire and smoke. The facility has a capacity for 25 and at the time of the survey the census was 19.

Findings include:

1. Observations on 9/14/10, revealed the corridor doors to the northwest corridor from the Home Health Storage Room did not close latch properly when tested.

2. Observations on 9/14/10, revealed the corridor door to the Auble Conference Room did not latch properly when tested.

3. Observations on 9/14/10, revealed the corridor door to Exam Room 4 did not latch properly when tested.

4. Observations on 9/14/10, revealed the corridor door to the Linen Closet by room 106B did not latch properly when tested.

5. Observations on 9/14/10, revealed the Employees Locker Room door on ground level did not close and latch properly when tested.

6. Observations on 9/14/10, revealed the corridor door to Room 202 did not latch properly when tested.

7. Observations on 9/14/10, revealed the fire doors in the ER Admitting area did not close and latch properly when tested.

8. Observations on 9/14/10, revealed the corridor door to Room 101 did not close and latch properly when tested.

9. Observations on 9/14/10, revealed the Clean Linen Closet next to room 114B did not close and latch properly when tested.

10. Observations on 9/14/10, revealed the corridor door to the 1st Floor Equipment Room (in Med Surg NW Wing) did not close and latch properly when tested.

Based on observations, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The facility is composed of protected combustible construction and unprotected noncombustible construction equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity for 25 and at the time of the survey the census was 19 residents.

Findings include:

1. Observations on 9/14/10, revealed a hole (approximately 2 inches in size) in the east wall of the Home Health Storage Room. Observations also revealed gaps (approximately 1/4 inch in size) around penetrations by sprinkler piping and cable above the corridor doors to the northwest corridor.

2. Observations on 9/14/10, revealed gaps (approximately 1/4 inch to 1/2 inch in size) around multiple penetrations in the corridor wall of the Maintenance Shop Entrance.

3. Observations on 9/14/10, revealed gaps (approximately 1/2 inch to 6 inches in size) around multiple penetrations by duct, conduit and pipes in the corridor wall of the West Elevator Mechanical Room.

4. Observations on 9/14/10, revealed gaps (approximately 2 inches in size) around penetrations by pipes and conduit in the Housekeeping Storage Room by the Business Office.

5. Observations on 9/14/10, revealed the Central Supply Store Room door did not close and latch properly when tested.

Based on observations, the facility failed maintain stairways free of storage in accordance with National Fire Protection Association (NFPA) Standard 101, 7.2.2.5.3. This facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Observations on 9/14/10, revealed miscellaneous combustible storage underneath the stairway near the conference room, Surgery, and the Emergency Room.

Based on observations, this facility is not providing an all-weather surface from the new Wellness Center and Therapy Clinic to a public way (an area of safety). This deficient practice could affect all occupants of this off site clinic and wellness facility with no inpatient beds.

Findings include:

Observations on 9/14/10, revealed the hard surface pad off the exit door from the Walking Track in the Wellness Center and from the Pool area terminated at a cement pad just outside the exit door and did not connect to the public way.

Based on observations, the facility failed to maintain the illumination of exit signs in accordance National Fire Protection Association (NFPA) Standard 101, 2000 edition, 7.10.5.2. Every sign shall be continuously illuminated. The facility has a capacity of 25 and at the time of the survey the census was 19.

Findings include:

Observations on 9/14/10, revealed the illuminated exit sign above the exit door in the stairway from South Hall Med Surg was not illuminated at the time of the survey.

Based on record review, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 19.

Findings include:

Review of the facility ' s fire drill records on 9/14/10, revealed fire drills were not conducted on the night shift of the second quarter and the day shift of the third quarter.

Based on record review, the facility failed to provide an appropriate fire alarm inspection report in accordance with the NFPA 72, 1999 edition, 7-5.2.2. A permanent record of all inspections, testing, and maintenance shall be provided that includes the information listed under 7-5.2.2 and all the applicable information requested in figure 7-5.2.2. All occupants of the facility could be affected by this deficient practice. This facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Record review of the the fire alarm test records on 9/14/10, revealed the fire alarm system was inspected, tested, and maintained by General Fire and Safety. The form was a single page and did not contain all the applicable information requested in Figure 7-5.2.2.

Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan can impede the operation of the smoke detector. This facility has a capacity of 25 and a census of 19.

Findings include:

Observations on 9/14/10, revealed smoke detectors were installed within 36 inches of air supplies or air returns in the following areas: Ultrasound Room, Radiology Entrance by Reading Room, by vending machines located in the corridor by the Main Entrance, in the corridor by the Auble Conference Room, and on the second floor outside of Exam Rooms 8, 9 and 10.

Based on observations, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition, 2-2.1.1. Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. Also the facility failed to maintain clearance between sprinkler heads and storage in accordance with NFPA 13, 1999 edition, 5-6.6. The clearance between the deflector and the top of storage shall be 18 inches or greater. Also the facility failed to maintain the hydraulic name plate attached to the sprinkler system riser legible. The facility has 25 certified beds and at the time of the survey the census was 19.

Findings include:

1. Observations on 9/14/10, revealed storage within 18 inches of the sprinkler head in the walk-in freezer in the Kitchen.

2. Observations on 9/14/10, revealed excessive lint/dust buildup on the sprinkler head in the corridor outside of the business office.

3. Observations on 9/14/10, revealed excessive lint/dust buildup on the sprinkler head in the ER Entrance Office area.

4. Observations on 9/14/10, revealed the hydraulic nameplate attached to the sprinkler riser in the Boiler Room was a sticker. The nameplate was deteriorated and a portion of it was illegible.

Based on observations, the facility failed to maintain one portable fire extinguisher in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. The facility has a capacity of 25 and at the time of the survey process the census was 19 residents.

Findings include:

1. Observations on 9/14/10, revealed a fire extinguisher on the floor in the ER Boiler Room. At the time of inspection, there was a bracket for the extinguisher but appeared to be damaged.

2. Observations on 9/14/10, revealed fire extinguishers indicating a need for recharge in the following locations: 1st Floor corridor next to exam room #6 and 1st Floor corridor next to exam room #2.

(A)
Based on record review and observations, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. The facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Observations on 9/14/10, revealed the facility was unable to provide documentation to show the wet chemical extinguishing system in the hood in the Kitchen had been provided with a monthly owners inspection.

(B)
Based on record review, the facility failed to maintain the commercial cooking suppression system in accordance with NFPA 96. The facility has a capacity of 25 and at the time of the survey process the census was 19.

Findings include:

Record review of the hood and duct system inspection reports on 9/14/10, revealed the system was inspected, tested, and maintained by General Fire and Safety. The following deficiency had been recorded on the 4/13/10 inspection report: "Fryer on end needs turned perpendicular to hood. Range and griddle needs repiped to accommodate back shelf. K class due for hydro 2010."

Based on observations and record review the facility failed to maintain the enclosure of the clean agent fire extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 2001, Standard on Clean Agent Fire Extinguishing Systems. To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. The protected enclosure shall have the structural strength and integrity necessary to contain the agent discharge. The facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Observations and record review on 9/14/10, revealed several ceiling tile had been moved out of the grid in the Server Room equipped with the clean agent fire extinguishing system. Record review of the inspection reports revealed the following deficiency had been noted: "As noted: 10/09 insp: Any opening in ceiling, walls, or floor will cause this system not to operate as designed, upon discharge. At the time of inspection , (6) six ceiling tiles are open."

Based on observations, 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. This facility has a capacity of 25 and a census of 19.

Findings include:

1. Observations on 9/14/10, revealed the numerous items blocking access to the electrical panels next to the corridor door in the Maintenance Room.

2. Observations on 9/14/10, revealed a fan plugged into a surge protector in the Medical Records Office.

3. Observations on 9/14/10, revealed electrical panel S-2 in the West Elevator Mechanical Room was missing a latch on the panel door.

Based on record review, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 19.

Findings include:

Record review of the facility's sprinkler system outage policy on 9/14/10, revealed the policy did not state a continuous fire watch would be conducted at least once every half hour. The policy stated the fire watch would be conducted once every hour.

Based on record review, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 19.

Findings include:

Record review of the facility's fire alarm system outage policy on 9/14/10, revealed the policy did not state a continuous fire watch would be conducted at least once every half hour. The policy stated the fire watch would be conducted once every hour.

Based on observation, the facility failed to maintain the doors within a two-hour fire wall to close and latch properly. This deficient practice would not prevent the spread of fire and smoke to another zone. This facility has a capacity of 25 and a census of 19.

Findings include:

Observations on 9/14/10, revealed the 90 minute door in the two-hour fire wall on the ground level to the stairway for the employee entrance near Central Supply did not latch properly when tested.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants as the doors would not prevent the spread of fire and smoke. The facility has a capacity for 25 and at the time of the survey the census was 19.

Findings include:

1. Observations on 9/14/10, revealed the corridor doors to the northwest corridor from the Home Health Storage Room did not close latch properly when tested.

2. Observations on 9/14/10, revealed the corridor door to the Auble Conference Room did not latch properly when tested.

3. Observations on 9/14/10, revealed the corridor door to Exam Room 4 did not latch properly when tested.

4. Observations on 9/14/10, revealed the corridor door to the Linen Closet by room 106B did not latch properly when tested.

5. Observations on 9/14/10, revealed the Employees Locker Room door on ground level did not close and latch properly when tested.

6. Observations on 9/14/10, revealed the corridor door to Room 202 did not latch properly when tested.

7. Observations on 9/14/10, revealed the fire doors in the ER Admitting area did not close and latch properly when tested.

8. Observations on 9/14/10, revealed the corridor door to Room 101 did not close and latch properly when tested.

9. Observations on 9/14/10, revealed the Clean Linen Closet next to room 114B did not close and latch properly when tested.

10. Observations on 9/14/10, revealed the corridor door to the 1st Floor Equipment Room (in Med Surg NW Wing) did not close and latch properly when tested.

Based on observations, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The facility is composed of protected combustible construction and unprotected noncombustible construction equipped with a sprinkler system. Where a sprinkler system option is used to provide separation, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. The facility has a capacity for 25 and at the time of the survey the census was 19 residents.

Findings include:

1. Observations on 9/14/10, revealed a hole (approximately 2 inches in size) in the east wall of the Home Health Storage Room. Observations also revealed gaps (approximately 1/4 inch in size) around penetrations by sprinkler piping and cable above the corridor doors to the northwest corridor.

2. Observations on 9/14/10, revealed gaps (approximately 1/4 inch to 1/2 inch in size) around multiple penetrations in the corridor wall of the Maintenance Shop Entrance.

3. Observations on 9/14/10, revealed gaps (approximately 1/2 inch to 6 inches in size) around multiple penetrations by duct, conduit and pipes in the corridor wall of the West Elevator Mechanical Room.

4. Observations on 9/14/10, revealed gaps (approximately 2 inches in size) around penetrations by pipes and conduit in the Housekeeping Storage Room by the Business Office.

5. Observations on 9/14/10, revealed the Central Supply Store Room door did not close and latch properly when tested.

Based on observations, the facility failed maintain stairways free of storage in accordance with National Fire Protection Association (NFPA) Standard 101, 7.2.2.5.3. This facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Observations on 9/14/10, revealed miscellaneous combustible storage underneath the stairway near the conference room, Surgery, and the Emergency Room.

Based on observations, this facility is not providing an all-weather surface from the new Wellness Center and Therapy Clinic to a public way (an area of safety). This deficient practice could affect all occupants of this off site clinic and wellness facility with no inpatient beds.

Findings include:

Observations on 9/14/10, revealed the hard surface pad off the exit door from the Walking Track in the Wellness Center and from the Pool area terminated at a cement pad just outside the exit door and did not connect to the public way.

Based on observations, the facility failed to maintain the illumination of exit signs in accordance National Fire Protection Association (NFPA) Standard 101, 2000 edition, 7.10.5.2. Every sign shall be continuously illuminated. The facility has a capacity of 25 and at the time of the survey the census was 19.

Findings include:

Observations on 9/14/10, revealed the illuminated exit sign above the exit door in the stairway from South Hall Med Surg was not illuminated at the time of the survey.

Based on record review, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 19.

Findings include:

Review of the facility ' s fire drill records on 9/14/10, revealed fire drills were not conducted on the night shift of the second quarter and the day shift of the third quarter.

Based on record review, the facility failed to provide an appropriate fire alarm inspection report in accordance with the NFPA 72, 1999 edition, 7-5.2.2. A permanent record of all inspections, testing, and maintenance shall be provided that includes the information listed under 7-5.2.2 and all the applicable information requested in figure 7-5.2.2. All occupants of the facility could be affected by this deficient practice. This facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Record review of the the fire alarm test records on 9/14/10, revealed the fire alarm system was inspected, tested, and maintained by General Fire and Safety. The form was a single page and did not contain all the applicable information requested in Figure 7-5.2.2.

Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan can impede the operation of the smoke detector. This facility has a capacity of 25 and a census of 19.

Findings include:

Observations on 9/14/10, revealed smoke detectors were installed within 36 inches of air supplies or air returns in the following areas: Ultrasound Room, Radiology Entrance by Reading Room, by vending machines located in the corridor by the Main Entrance, in the corridor by the Auble Conference Room, and on the second floor outside of Exam Rooms 8, 9 and 10.

Based on observations, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition, 2-2.1.1. Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. Also the facility failed to maintain clearance between sprinkler heads and storage in accordance with NFPA 13, 1999 edition, 5-6.6. The clearance between the deflector and the top of storage shall be 18 inches or greater. Also the facility failed to maintain the hydraulic name plate attached to the sprinkler system riser legible. The facility has 25 certified beds and at the time of the survey the census was 19.

Findings include:

1. Observations on 9/14/10, revealed storage within 18 inches of the sprinkler head in the walk-in freezer in the Kitchen.

2. Observations on 9/14/10, revealed excessive lint/dust buildup on the sprinkler head in the corridor outside of the business office.

3. Observations on 9/14/10, revealed excessive lint/dust buildup on the sprinkler head in the ER Entrance Office area.

4. Observations on 9/14/10, revealed the hydraulic nameplate attached to the sprinkler riser in the Boiler Room was a sticker. The nameplate was deteriorated and a portion of it was illegible.

Based on observations, the facility failed to maintain one portable fire extinguisher in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. The facility has a capacity of 25 and at the time of the survey process the census was 19 residents.

Findings include:

1. Observations on 9/14/10, revealed a fire extinguisher on the floor in the ER Boiler Room. At the time of inspection, there was a bracket for the extinguisher but appeared to be damaged.

2. Observations on 9/14/10, revealed fire extinguishers indicating a need for recharge in the following locations: 1st Floor corridor next to exam room #6 and 1st Floor corridor next to exam room #2.

(A)
Based on record review and observations, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. The facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Observations on 9/14/10, revealed the facility was unable to provide documentation to show the wet chemical extinguishing system in the hood in the Kitchen had been provided with a monthly owners inspection.

(B)
Based on record review, the facility failed to maintain the commercial cooking suppression system in accordance with NFPA 96. The facility has a capacity of 25 and at the time of the survey process the census was 19.

Findings include:

Record review of the hood and duct system inspection reports on 9/14/10, revealed the system was inspected, tested, and maintained by General Fire and Safety. The following deficiency had been recorded on the 4/13/10 inspection report: "Fryer on end needs turned perpendicular to hood. Range and griddle needs repiped to accommodate back shelf. K class due for hydro 2010."

Based on observations and record review the facility failed to maintain the enclosure of the clean agent fire extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 2001, Standard on Clean Agent Fire Extinguishing Systems. To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. The protected enclosure shall have the structural strength and integrity necessary to contain the agent discharge. The facility has a capacity of 25 and at the time of the survey had a census of 19.

Findings include:

Observations and record review on 9/14/10, revealed several ceiling tile had been moved out of the grid in the Server Room equipped with the clean agent fire extinguishing system. Record review of the inspection reports revealed the following deficiency had been noted: "As noted: 10/09 insp: Any opening in ceiling, walls, or floor will cause this system not to operate as designed, upon discharge. At the time of inspection , (6) six ceiling tiles are open."

Based on observations, 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. This facility has a capacity of 25 and a census of 19.

Findings include:

1. Observations on 9/14/10, revealed the numerous items blocking access to the electrical panels next to the corridor door in the Maintenance Room.

2. Observations on 9/14/10, revealed a fan plugged into a surge protector in the Medical Records Office.

3. Observations on 9/14/10, revealed electrical panel S-2 in the West Elevator Mechanical Room was missing a latch on the panel door.

Based on record review, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 19.

Findings include:

Record review of the facility's sprinkler system outage policy on 9/14/10, revealed the policy did not state a continuous fire watch would be conducted at least once every half hour. The policy stated the fire watch would be conducted once every hour.

Based on record review, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 19.

Findings include:

Record review of the facility's fire alarm system outage policy on 9/14/10, revealed the policy did not state a continuous fire watch would be conducted at least once every half hour. The policy stated the fire watch would be conducted once every hour.