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Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the door on the janitor closet at room #169 and the storage room leading to the patient room in the walk-in clinic in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 3/19/12 at approximately 11:37am, by observation and interview of the Plant Operations Director the door on the janitor closet at room #169 failed to properly closed and latch. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:39am, by observation and interview of the Plant Operations Director the door on the storage room leading to the patient room in the walk-in clinic failed to properly closed and latch. This finding was verified with the Plant Operations Director at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke walls in the main electrical room, ceiling of the boiler room, ceiling at the smoke barrier wall at the Business Office, corridor wall at the CT Scan room and the corridor wall at the Physical Therapy #2 Room in accordance with the LSC, section 19.3.7.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 3/19/12 at approximately 11:03am, by observation and interview of the Plant Operations Director penetrations of the smoke barrier wall in the main electrical room failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:05am, by observation and interview of the Plant Operations Director penetrations of the smoke barrier wall on the ceiling of the boiler room failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:19am, by observation and interview of the Plant Operations Director penetrations of the smoke barrier wall in the ceiling at the smoke barrier wall at the Business Office failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:24am, by observation and interview of the Plant Operations Director penetrations of the corridor wall at the CT Scan room failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:35am, by observation and interview of the Plant Operations Director penetrations of the corridor wall at the Physical Therapy #2 Room failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure the generator had a performance of a FULL LOAD BANK test in accordance with NFPA 99, section 3.4.4.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 3/19/12 at approximately 10:21am, during record review and interview of the Plant Operations Director, records were not available for verification of a performance of a FULL LOAD BANK test. This finding was verified with the Plant Operations Director at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that electrical wiring to be in accordance with NFPA 70, National Electrical Code, section 9.1.2 by failing to cover an open electrical junction box above the ceiling at the Bone Density Room and having combustibles stored in front of electrical panels in the Main Electrical Room. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 3/19/12 at approximately 11:00am, by observation and interview of the Plant Operations Director, the facility failed to cover an open electrical junction box above the ceiling at the Bone Density Room. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:03am, by observation and interview of the Plant Operations Director, the facility was storing combustibles in front of electrical panels in the Main Electrical Room. This finding was verified with the Plant Operations Director at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the door on the janitor closet at room #169 and the storage room leading to the patient room in the walk-in clinic in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 3/19/12 at approximately 11:37am, by observation and interview of the Plant Operations Director the door on the janitor closet at room #169 failed to properly closed and latch. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:39am, by observation and interview of the Plant Operations Director the door on the storage room leading to the patient room in the walk-in clinic failed to properly closed and latch. This finding was verified with the Plant Operations Director at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke walls in the main electrical room, ceiling of the boiler room, ceiling at the smoke barrier wall at the Business Office, corridor wall at the CT Scan room and the corridor wall at the Physical Therapy #2 Room in accordance with the LSC, section 19.3.7.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 3/19/12 at approximately 11:03am, by observation and interview of the Plant Operations Director penetrations of the smoke barrier wall in the main electrical room failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:05am, by observation and interview of the Plant Operations Director penetrations of the smoke barrier wall on the ceiling of the boiler room failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:19am, by observation and interview of the Plant Operations Director penetrations of the smoke barrier wall in the ceiling at the smoke barrier wall at the Business Office failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:24am, by observation and interview of the Plant Operations Director penetrations of the corridor wall at the CT Scan room failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:35am, by observation and interview of the Plant Operations Director penetrations of the corridor wall at the Physical Therapy #2 Room failed to be properly sealed. This finding was verified with the Plant Operations Director at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure the generator had a performance of a FULL LOAD BANK test in accordance with NFPA 99, section 3.4.4.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 3/19/12 at approximately 10:21am, during record review and interview of the Plant Operations Director, records were not available for verification of a performance of a FULL LOAD BANK test. This finding was verified with the Plant Operations Director at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that electrical wiring to be in accordance with NFPA 70, National Electrical Code, section 9.1.2 by failing to cover an open electrical junction box above the ceiling at the Bone Density Room and having combustibles stored in front of electrical panels in the Main Electrical Room. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 3/19/12 at approximately 11:00am, by observation and interview of the Plant Operations Director, the facility failed to cover an open electrical junction box above the ceiling at the Bone Density Room. This finding was verified with the Plant Operations Director at the time of discovery.

On 3/19/12 at approximately 11:03am, by observation and interview of the Plant Operations Director, the facility was storing combustibles in front of electrical panels in the Main Electrical Room. This finding was verified with the Plant Operations Director at the time of discovery.