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Based on observation, the facility failed to maintain a single, corridor door. It is essential that corridor doors be quickly closed and secured in the event of a fire to prevent the spread of fire and/or smoke to or from other areas of the facility. This deficient practice affected staff and residents throughout one smoke compartment.

Findings include:

During a test of the fire alarm system, the surveyor along with the Director of Facilities observed that the a hallway door within smoke compartment 5 ("Housekeeping/Materials Management") failed to close and latch during a test of the fire alarm system. Air pressure was an impediment to the securing of this corridor door. This condition continued until the door was re-attached to its magnetic hold-open.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.

Based on observation, the facility failed to maintain smoke doors that would resist the passage of smoke. It is essential that corridor doors be quickly closed and secured in the event of a fire to prevent the spread of fire and or smoke to, or from, other areas of the facility. The deficient practice affected two of eleven smoke compartments, staff and patients. The facility has the capacity for 25 licensed beds and had a census of eight.

Findings include:

During a test of the fire alarm system, the surveyor along with the Director of Facilities observed that the cross-corridor doors separating smoke compartments four and five (ground floor), would open and close approximately three to five inches depending upon which nearby, exit door was being opened. Air pressure was an impediment to keeping the doors closed.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.

NFPA 25, 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 (e.g., upright, pendant, or sidewall). Any sprinkler hall be replaced that is painted, corroded, damaged, loaded or in the improper orientation.
Exception #1: Sprinklers installed in concealed spaces such as above the suspended ceiling shall not require inspection.
Exception #2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

This STANDARD was not met, as evidenced by:

Based on observation, the facility failed to maintain the integrity of the automatic sprinkler heads. In the event of a fire, the activation and effective operation of the automatic sprinkler system may not occur if sprinkler heads are not properly maintained. This deficient practice affected staff and residents in the exterior entry area of the facility.

Findings include:

During a tour of the facility on 12/09/11, the surveyor along with Director of Facilities observed sprinkler heads in the drive-under canopy at the hospital's main entrance. Three of 28 exterior sprinklers had bees/spider nests built in them.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.

NFPA 10, 2002 edition, Section 1-5.11
Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location shall be marked conspicuously.

This STANDARD was not met as evidenced by:

Based on observation the facility failed to provide conspicuous markers to readily identify the location of portable fire extinguishers in corridors throughout the facility. This deficient practice affected staff and patients throughout the facility. At the time of survey, the census was 8 and the licensed capacity was 25.

Findings include:

During the tour of the facility on 12/08/11, the surveyor along with the Director of Facilities observed that the location of fire extinguishers in recessed wall cabinets was not apparent when looking down corridors.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure


This STANDARD was not met as evidenced by:

Based on observation, the facility did not prohibit the use of extension cords, power strips, and adapters as a substitute for adequate wiring to prevent overloaded circuits. This deficient practice could result in an increased risk of an electrical fire resulting in potential harm to the residents as well as staff. This deficient practice affected staff and patients in three of eleven smoke compartments. At the time of the survey the census was 8 and the licensed capacity was 25.

Findings include:

During a tour of the facility on 12/8-9/11, the surveyor along with the Director of Facilities observed power strips, and/or adapters that were not maintained in the following locations:
a) Housekeeping- One extension cord serving; a refrigerator, microwave and toaster.
b) Materials Management- Two cords serving; fax, printer, and microwave.
c) Radiology Viewing Room- Two cords serving diagnostic equipment.
d) MRI Room- One cord.
e) Emergency Dept.- One cord serving a blanket warmer and refrigerator temperature monitor.
f) Director of Facilities Office- Two cords serving office equipment and a television set.
g) Conference Room (Admin.)- One cord serving a computer and telecommunications equipment.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.


Note: The facility must be mindful to ensure that the capacity for the circuits do not get overloaded. Mapping of the circuits within the building is strongly recommended for monitoring and re-assigning electrical appliances as needed.

Based on observation, the facility failed to maintain a single, corridor door. It is essential that corridor doors be quickly closed and secured in the event of a fire to prevent the spread of fire and/or smoke to or from other areas of the facility. This deficient practice affected staff and residents throughout one smoke compartment.

Findings include:

During a test of the fire alarm system, the surveyor along with the Director of Facilities observed that the a hallway door within smoke compartment 5 ("Housekeeping/Materials Management") failed to close and latch during a test of the fire alarm system. Air pressure was an impediment to the securing of this corridor door. This condition continued until the door was re-attached to its magnetic hold-open.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.

Based on observation, the facility failed to maintain smoke doors that would resist the passage of smoke. It is essential that corridor doors be quickly closed and secured in the event of a fire to prevent the spread of fire and or smoke to, or from, other areas of the facility. The deficient practice affected two of eleven smoke compartments, staff and patients. The facility has the capacity for 25 licensed beds and had a census of eight.

Findings include:

During a test of the fire alarm system, the surveyor along with the Director of Facilities observed that the cross-corridor doors separating smoke compartments four and five (ground floor), would open and close approximately three to five inches depending upon which nearby, exit door was being opened. Air pressure was an impediment to keeping the doors closed.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.

NFPA 25, 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 (e.g., upright, pendant, or sidewall). Any sprinkler hall be replaced that is painted, corroded, damaged, loaded or in the improper orientation.
Exception #1: Sprinklers installed in concealed spaces such as above the suspended ceiling shall not require inspection.
Exception #2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

This STANDARD was not met, as evidenced by:

Based on observation, the facility failed to maintain the integrity of the automatic sprinkler heads. In the event of a fire, the activation and effective operation of the automatic sprinkler system may not occur if sprinkler heads are not properly maintained. This deficient practice affected staff and residents in the exterior entry area of the facility.

Findings include:

During a tour of the facility on 12/09/11, the surveyor along with Director of Facilities observed sprinkler heads in the drive-under canopy at the hospital's main entrance. Three of 28 exterior sprinklers had bees/spider nests built in them.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.

NFPA 10, 2002 edition, Section 1-5.11
Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location shall be marked conspicuously.

This STANDARD was not met as evidenced by:

Based on observation the facility failed to provide conspicuous markers to readily identify the location of portable fire extinguishers in corridors throughout the facility. This deficient practice affected staff and patients throughout the facility. At the time of survey, the census was 8 and the licensed capacity was 25.

Findings include:

During the tour of the facility on 12/08/11, the surveyor along with the Director of Facilities observed that the location of fire extinguishers in recessed wall cabinets was not apparent when looking down corridors.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.

NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure


This STANDARD was not met as evidenced by:

Based on observation, the facility did not prohibit the use of extension cords, power strips, and adapters as a substitute for adequate wiring to prevent overloaded circuits. This deficient practice could result in an increased risk of an electrical fire resulting in potential harm to the residents as well as staff. This deficient practice affected staff and patients in three of eleven smoke compartments. At the time of the survey the census was 8 and the licensed capacity was 25.

Findings include:

During a tour of the facility on 12/8-9/11, the surveyor along with the Director of Facilities observed power strips, and/or adapters that were not maintained in the following locations:
a) Housekeeping- One extension cord serving; a refrigerator, microwave and toaster.
b) Materials Management- Two cords serving; fax, printer, and microwave.
c) Radiology Viewing Room- Two cords serving diagnostic equipment.
d) MRI Room- One cord.
e) Emergency Dept.- One cord serving a blanket warmer and refrigerator temperature monitor.
f) Director of Facilities Office- Two cords serving office equipment and a television set.
g) Conference Room (Admin.)- One cord serving a computer and telecommunications equipment.

The above findings were acknowledged by the facility's Administrator and Director of Facilities during the exit conference on 12/09/11.


Note: The facility must be mindful to ensure that the capacity for the circuits do not get overloaded. Mapping of the circuits within the building is strongly recommended for monitoring and re-assigning electrical appliances as needed.