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Based on observation the doors listed below did not have latches on them, as required by the LSC(00) Section 19. 3.6.3. This deficient practice could affect all residents, staff, and visitors, in the event of a fire.

Findings include:

During the facility tour on 6-22-10, between 8:30-10:30 AM it was observed that the doors of the below listed rooms did not have latches on them.

A. Doors to lower level mens and womens lockers rooms (2).

B. Door to cafeteria (1)

C. Door to the kitchen (1)

D. Pharmacy central supply (1).

This deficient practice was confirmed by the facility Director of Maintenance (AF) at the time of discovery.

Based on observation the exit doors in the "Safe Harbor" wing are secured electronically. The doors are equipped with a key pad to release the locks. However, the combination for the locks are not located on the doors as required by LSC(00) Section 19.2.2.2.5. This deficient practice could effect all patients, staff and visitors.

Findings include:

During the facility tour on 3-16-10 at 10:00AM it was observed that the combination for key pad of the exit stairwell (South end) door into the stairwell was not posted, on the door. Further it was not verified if this door could be unlocked from the nurses station.

These deficient practices were confirmed by the Director of Maintenance (AF) at the time of exit.

Based on observation, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all occupants including all patients, staff and visitors.

Findings include:

During the facility tour between on 6-22-10 between 9:00-10:00AM it was observed that two (2) of the system connected smoke detectors are located within 3 feet of HVAC deflectors. They are located in the following areas:

A. The "body room" in the basement.

B. In the laundry, in the basement.

This deficient practice was confirmed by the Maintenance Supervisor (AF at the time of exit.

Based on observation and staff interview, the facility failed to provide proper installation of the fire sprinkler heads as per 2000 NFPA 101, 19.3.5.1 and 1998 NFPA 25, section 2-2.1.1 and 2002 NFPA 25, Chapter 5.3.1.1.1.5 . The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between between 8:30-11:00 AM between 8:30-11:00 AM it was observed,

A. No automatic fire sprinkler head in "Al's closet".

B. No automatic fire sprinkler head in the "body room" lower level.

This deficient practice was confirmed by Maintenance Director (AF) at the time of discovery.

It was observed that the mechanical room, in the basement is being used for storage of combustibles. This does not meet the requiresments of MSFC(06) Section 315.2.3 & Section 605.3. This deficient practice could effect all visitors, staff, and residents.

Findings include:

Based on observation on 6-22-10 at 10:00AM it was observed that the large mechanical room in the basement (west end) is being used as a storage area for combustible materials.

This deficient practice was confirmed by the facility Director of Maintenance (AF) at the time of discovery.

Based on observation the doors listed below did not have latches on them, as required by the LSC(00) Section 19. 3.6.3. This deficient practice could affect all residents, staff, and visitors, in the event of a fire.

Findings include:

During the facility tour on 6-22-10, between 8:30-10:30 AM it was observed that the doors of the below listed rooms did not have latches on them.

A. Doors to lower level mens and womens lockers rooms (2).

B. Door to cafeteria (1)

C. Door to the kitchen (1)

D. Pharmacy central supply (1).

This deficient practice was confirmed by the facility Director of Maintenance (AF) at the time of discovery.

Based on observation the exit doors in the "Safe Harbor" wing are secured electronically. The doors are equipped with a key pad to release the locks. However, the combination for the locks are not located on the doors as required by LSC(00) Section 19.2.2.2.5. This deficient practice could effect all patients, staff and visitors.

Findings include:

During the facility tour on 3-16-10 at 10:00AM it was observed that the combination for key pad of the exit stairwell (South end) door into the stairwell was not posted, on the door. Further it was not verified if this door could be unlocked from the nurses station.

These deficient practices were confirmed by the Director of Maintenance (AF) at the time of exit.

Based on observation, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all occupants including all patients, staff and visitors.

Findings include:

During the facility tour between on 6-22-10 between 9:00-10:00AM it was observed that two (2) of the system connected smoke detectors are located within 3 feet of HVAC deflectors. They are located in the following areas:

A. The "body room" in the basement.

B. In the laundry, in the basement.

This deficient practice was confirmed by the Maintenance Supervisor (AF at the time of exit.

Based on observation and staff interview, the facility failed to provide proper installation of the fire sprinkler heads as per 2000 NFPA 101, 19.3.5.1 and 1998 NFPA 25, section 2-2.1.1 and 2002 NFPA 25, Chapter 5.3.1.1.1.5 . The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between between 8:30-11:00 AM between 8:30-11:00 AM it was observed,

A. No automatic fire sprinkler head in "Al's closet".

B. No automatic fire sprinkler head in the "body room" lower level.

This deficient practice was confirmed by Maintenance Director (AF) at the time of discovery.

It was observed that the mechanical room, in the basement is being used for storage of combustibles. This does not meet the requiresments of MSFC(06) Section 315.2.3 & Section 605.3. This deficient practice could effect all visitors, staff, and residents.

Findings include:

Based on observation on 6-22-10 at 10:00AM it was observed that the large mechanical room in the basement (west end) is being used as a storage area for combustible materials.

This deficient practice was confirmed by the facility Director of Maintenance (AF) at the time of discovery.