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Based on observations and staff interview, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type V (111) construction. This deficiency had the potential to affect more than a very limited number of residents, staff and visitors in the building.

Findings include:

1. The beauty shop was observed on 9/17/13 at 10:00 a.m. The corner of the ceiling above the cabinets had two unsealed cut out sections, one measuring approximately 1.5 inch by 1.5 inch and the other approximately 1.5 inch in diameter.

2. The penthouse housing air handling unit (AHU)-1 was observed at 10:45 a.m. on 9/17/13. Two unsealed wall cut outs, one measuring approximately 3.5 inches in diameter (around a sprinkler pipe) and the other measuring approximately 2.5 inches in diameter (around multiple data cables), were observed on the east wall of the penthouse.

3. The mechanical room (the old boiler room) was examined at 1:44 p.m. on 9/17/13. The following was observed:

a. A pipe, no longer in service, measuring approximately 1.5 inches in diameter extended through the ceiling and its open end was not sealed.

b. A communication cable extended through the ceiling and the penetration around it was not sealed.

c. Another water pipe extended through the damaged ceiling surface and the penetration around it was not repaired and sealed.

Based on observations, the facility failed to maintain the fire resistive construction of all corridor walls to resist the passage of smoke. This deficiency had potential to affect more than a very limited number of patients, staff and visitors in the building.

Findings include:

In accordance with Section 19.3.6.2.1 of NFPA 101, corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

The main Server room was examined at 10:58 a.m. on 9/17/13. Several data cables were extending through an unsealed penetration through the server wall into the corridor side of the wall above the room door. The penetration measured approximately 2.5 inches in diameter.

Based on observations, the facility failed to ensure that all corridor doors latched positively without any impediment preventing the latching mechanism from failure. This deficiency had the potential to affect a very limited number of residents, staff and visitors in the building.

Findings include:

The forces required to fully open any door manually in a means of egress shall not exceed 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width per section 7.2.1.4.5 of the NFPA 101 Life Safety Code, 2000 Edition.

The corridor door to room 201 was examined at 1:13 p.m. on 9/17/13. When exercised, the door would not close as it was shifted down and did not fit in the frame. The latching mechanism and the frame could not meet.

Based on observation, the facility failed to ensure that between floor construction rating in a building of Type V(111) construction was maintained not less than a 1-hour fire resistance. This deficiency had the potential to affect more than a very limited number of occupants in the facility in two smoke compartments.

Findings include:

1. During the observation of the penthouse housing AHUs 2 and 3 on 9/17/13 at 10:36 a.m., the surveyor noted two vertical unsealed penetrations extending through the floor.

2. The door to the penthouse housing AHU -1 was exercised on 9/17/13 at 10:42 a.m. The door had a self closure device and failed to positively latch during the examination.

3. During the observation of the penthouse housing AHU-1 on 9/17/13 at 10:45 a.m., an unsealed conduit penetration was observed through the penthouse floor.

Based on observation, the facility failed to maintain the smoke and fire resistance rating for two of two smoke/fire barrier walls. This deficiency had the potential to affect more than a very limited number of occupants in two of the four smoke compartments in the facility.

Findings include:

In accordance with the Section 19.3.7.3. of NFPA 101, 2000 Edition, any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Additionally, in accordance with Section 8.3.6.1 (1) a and b of NFPA 101, 2000 Edition; pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected by filling the space between the penetrating item and the smoke barrier with a material that is capable of maintaining the smoke resistance of the smoke barrier or it shall be protected by an approved device that is designed for the specific purpose.

1. The smoke barrier walls on Timber Creek, Spring Creek, and Zone 4 were observed between 9:30 a.m. and 9:45 a.m. on 9/17/13. Total of five unsealed penetrations were observed around multiple data and fire alarm cables where they extended through the smoke walls.

2. An additional penetration was observed at 10:16 a.m. during the examination of the dampers, on the corner of the wall above the ceiling tiles next to the Tub Room on Spring Creek hall. All penetrations had to be sealed on both sides of the smoke barriers.

Based on observations, the facility failed to ensure doors protecting hazardous areas closed and latched with the efforts of the self-closing mechanism. This deficiency had the potential to affect more than a very limited number of residents, staff and visitors in the building.

Findings include:

In accordance with NFPA 101 and Section 19.3.2.1, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

1. The Lab was observed at 11:04 a.m. on 9/17/13. An unsealed phone cable penetration was observed in the corner of the ceiling above the main entrance door where it exited into the corridor. Two additional unsealed penetrations were observed through the ceiling above the lab's secondary exit door where multiple data cables extended through the ceiling.

2. The basement Central Supply/Medical Records was observed at 11:16 a.m. on 9/17/13. The 90-minute fire rated door with self closure was held open with a container of Action Melt, snow melt product and a folded piece of paper that was placed under the open door. Additionally, the door failed to latch positively when it was exercised.

Based on record review, staff interview, and observation, the facility failed to ensure the monthly and annual tests of battery-powered emergency lights tests were performed and documented. This deficiency could affect all staff, residents and visitors in the facility.

Findings included:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one half hours.

The maintenance logs were reviewed at the facility on 9/17/13. No documentation was available in the maintenance logs for the periodic testing of the emergency battery backup lighting located in the garage where the generator was located and in the maintenance office where the generator transfer switch was located.

The battery powered emergency light fixture located in the maintenance office (housed the generator transfer switch) was exercised at 1:52 p.m. on 9/17/13. The unit failed to illuminate. The unit lacked battery power. Staff member A verified that he didn't know he had to test these units monthly and once annually.

Based on record review and staff interview, the facility failed to ensure that on fire drills conducted between during all shifts within each quarter. This deficiency could affect more than a very limited amount of residents, staff and visitors in the facility.

Findings include:

The fire drill reports were reviewed at the facility at 8:55 a.m. on 9/17/13. The fire drills affect the entire facility and all residents. The facility utilized three shifts for the certified nurse aides. According to the logs:

a. For the October - December 2012 quarter, the night shift (11:00 a.m. to 7:00 a.m.) drill log was missing.

b. For the January - March 2013 quarter, the afternoon (3:00 p.m. to 11:00 p.m.) and the night shift drill logs were missing.

c. For the April - June 2013 quarter, the night shift (11:00 a.m. to 7:00 a.m.) drill log was missing.

On 9/17/13 at 3:30 p.m. staff member A stated he thought he only had to conduct two drills quarterly since the nurses worked 12 hour shifts.

Based on observations and staff interviews, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system. The deficiency could affect all residents, staff, and visitors in the building.

Findings include:

The building is of Type V (111) combustible construction which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 standards per NFPA 101 and Section 19.1.6.2.

1. The clinic was surveyed at 11:15 a.m. on 9/17/13. The closet located behind the entrance to the clinic, in the clinic waiting room, lacked automatic sprinkler coverage.

2. The secondary exit from the basement (Central Supply/Medical Records) was observed at 11:21 a.m. on 9/17/13. The canopy over the landing and the canopy over the stairs were not sprinklered. The canopy over the landing was wood construction. The canopy over the stairwell had a metal cover. Staff member A, who was accompanying the surveyor, said he did not know the construction type of the canopy, but it was a possibility that it was wood.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with the requirements in NFPA 13, 1999 Edition. This deficiency had the potential to affect more than a very limited number of residents, staff and the visitors in the building.

Findings include:

In accordance with NFPA 13 and Section 3-2.7.2, escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further, the code states in Annex A-3-2.7.2, the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. On 9/17/13 at 10:05 a.m., the walk-in cooler in the kitchen was observed. The escutcheon ring was loose around the automatic sprinkler pipe creating an annular space between the ring and the ceiling surface.

2. On 9/17/13 at 10:30 a.m., an annular space was observed between the sprinkler head where the sprinkler pipe shifted down and the escutcheon ring was not flush with the ceiling surface in front of the penthouse entry door in Zone 4.

3. On 9/17/13 at 10:57 a.m., an annular space was observed between the sprinkler head and the solid ceiling surface in the Server room where the ceiling appeared to be damaged around the escutcheon ring.

Based on observation and interviews, the facility failed to ensure baffle filters located in the kitchen hood were installed properly between washes per NFPA 96, 1998 Edition. This deficiency had the potential to affect a very limited amount of residents, staff, and visitors.

Findings include:

In accordance with NFPA 96 and Section 3-2.7, grease filters that require a specific orientation to drain grease shall be clearly so designated, or the hood shall be constructed so that filters cannot be installed in the wrong orientation.

The kitchen was observed on 9/17/13 at 10:03 a.m. The one of the three baffle filters (the middle one) located in the kitchen hood was installed in the wrong orientation and needed to be rotated 90 degrees so grease can be directed to the drip tray. The filters should be installed per manufacturers recommendations.

Based on observation, the facility failed to ensure that oxygen was stored safely in accordance with NFPA 99 Chapter 4 Gas and Vacuum Systems and specifically 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). This deficiency could affect more than a very limited number of residents and staff in the building.

Findings include:

Outside oxygen storage was observed at 2:05 p.m. on 9/17/13. The location contained approximately 50 E size, and 14 K size, and a number of D size oxygen cylinders. The storage was not locked in an enclosed space. Staff member A stated the shed behind the storage was built for the oxygen, but it became other storage.

Based on observations, the facility failed to ensure that smoke dampers interconnected to the facility fire alarm system closed upon the activation of the fire alarm system. This deficiency had potential to affect almost all of the residents, staff and visitors in two smoke compartments.

Findings include:

If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of Heating, Ventilation, and Air Conditioning (HVAC) systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity, including relays that cause the dampers to close and open upon activation and reset of the fire alarm system per section 3-9.5.2 of NFPA 72, 1999 Edition.

The smoke dampers were exercised between 10:15 a.m. and 10:28 a.m. on 9/17/13. All four of the dampers (two in the barrier wall in Timber Creek and two in Spring Creek) stayed opened when the fire alarms were activated in these two different smoke compartments.

Based on record review and staff interview, the facility failed to ensure weekly visual inspections completed on the generator were documented. This deficiency could affect all residents, staff, and visitors in the building.

Findings include:

Generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99 3.4.4.1.

The generator test and inspection reports were reviewed at the facility on 9/17/13 at 8:37 a.m. and later at 1:52 p.m. near the generator's location. The weekly inspection reports/logs for the generator were not available for review. Staff member A stated he did not document the weekly visual tests.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies have the potential to affect more than a limited number of residents, staff and visitors in the basement of the building.

Findings include:

In accordance with 240-4 of the NFPA 70 (1999 Edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 Edition) and previous interpretations from CMS (transmittal notice dated 3-30-99) extension cords or multiple adaptors used in health care shall be protected against over-current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS); one means is by providing surge strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.
The limited use of circuit breaker protected power strips is acceptable, provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

In accordance with NFPA 70 and Article 370-25, in completed installations, each box shall have a cover, faceplate, or fixture canopy.

1. The electrical junction box, found above the ceiling tiles at the 2-hour fire wall separation near the ER, had a missing cover at 10:14 a.m. 9/17/13.

2. A vending machine (Coke) was observed in Zone 4 near ER at 11:01 a.m. on 9/17/13. The unit was plugged into a power tap.

3. The administration office was observed at 1:24 p.m. on 9/17/13. Two power strips were plugged into each other under the receptionist's desk. Several equipment was plugged into the power taps.

Based on observations and staff interview, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type V (111) construction. This deficiency had the potential to affect more than a very limited number of residents, staff and visitors in the building.

Findings include:

1. The beauty shop was observed on 9/17/13 at 10:00 a.m. The corner of the ceiling above the cabinets had two unsealed cut out sections, one measuring approximately 1.5 inch by 1.5 inch and the other approximately 1.5 inch in diameter.

2. The penthouse housing air handling unit (AHU)-1 was observed at 10:45 a.m. on 9/17/13. Two unsealed wall cut outs, one measuring approximately 3.5 inches in diameter (around a sprinkler pipe) and the other measuring approximately 2.5 inches in diameter (around multiple data cables), were observed on the east wall of the penthouse.

3. The mechanical room (the old boiler room) was examined at 1:44 p.m. on 9/17/13. The following was observed:

a. A pipe, no longer in service, measuring approximately 1.5 inches in diameter extended through the ceiling and its open end was not sealed.

b. A communication cable extended through the ceiling and the penetration around it was not sealed.

c. Another water pipe extended through the damaged ceiling surface and the penetration around it was not repaired and sealed.

Based on observations, the facility failed to maintain the fire resistive construction of all corridor walls to resist the passage of smoke. This deficiency had potential to affect more than a very limited number of patients, staff and visitors in the building.

Findings include:

In accordance with Section 19.3.6.2.1 of NFPA 101, corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

The main Server room was examined at 10:58 a.m. on 9/17/13. Several data cables were extending through an unsealed penetration through the server wall into the corridor side of the wall above the room door. The penetration measured approximately 2.5 inches in diameter.

Based on observations, the facility failed to ensure that all corridor doors latched positively without any impediment preventing the latching mechanism from failure. This deficiency had the potential to affect a very limited number of residents, staff and visitors in the building.

Findings include:

The forces required to fully open any door manually in a means of egress shall not exceed 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width per section 7.2.1.4.5 of the NFPA 101 Life Safety Code, 2000 Edition.

The corridor door to room 201 was examined at 1:13 p.m. on 9/17/13. When exercised, the door would not close as it was shifted down and did not fit in the frame. The latching mechanism and the frame could not meet.

Based on observation, the facility failed to ensure that between floor construction rating in a building of Type V(111) construction was maintained not less than a 1-hour fire resistance. This deficiency had the potential to affect more than a very limited number of occupants in the facility in two smoke compartments.

Findings include:

1. During the observation of the penthouse housing AHUs 2 and 3 on 9/17/13 at 10:36 a.m., the surveyor noted two vertical unsealed penetrations extending through the floor.

2. The door to the penthouse housing AHU -1 was exercised on 9/17/13 at 10:42 a.m. The door had a self closure device and failed to positively latch during the examination.

3. During the observation of the penthouse housing AHU-1 on 9/17/13 at 10:45 a.m., an unsealed conduit penetration was observed through the penthouse floor.

Based on observation, the facility failed to maintain the smoke and fire resistance rating for two of two smoke/fire barrier walls. This deficiency had the potential to affect more than a very limited number of occupants in two of the four smoke compartments in the facility.

Findings include:

In accordance with the Section 19.3.7.3. of NFPA 101, 2000 Edition, any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Additionally, in accordance with Section 8.3.6.1 (1) a and b of NFPA 101, 2000 Edition; pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected by filling the space between the penetrating item and the smoke barrier with a material that is capable of maintaining the smoke resistance of the smoke barrier or it shall be protected by an approved device that is designed for the specific purpose.

1. The smoke barrier walls on Timber Creek, Spring Creek, and Zone 4 were observed between 9:30 a.m. and 9:45 a.m. on 9/17/13. Total of five unsealed penetrations were observed around multiple data and fire alarm cables where they extended through the smoke walls.

2. An additional penetration was observed at 10:16 a.m. during the examination of the dampers, on the corner of the wall above the ceiling tiles next to the Tub Room on Spring Creek hall. All penetrations had to be sealed on both sides of the smoke barriers.

Based on observations, the facility failed to ensure doors protecting hazardous areas closed and latched with the efforts of the self-closing mechanism. This deficiency had the potential to affect more than a very limited number of residents, staff and visitors in the building.

Findings include:

In accordance with NFPA 101 and Section 19.3.2.1, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

1. The Lab was observed at 11:04 a.m. on 9/17/13. An unsealed phone cable penetration was observed in the corner of the ceiling above the main entrance door where it exited into the corridor. Two additional unsealed penetrations were observed through the ceiling above the lab's secondary exit door where multiple data cables extended through the ceiling.

2. The basement Central Supply/Medical Records was observed at 11:16 a.m. on 9/17/13. The 90-minute fire rated door with self closure was held open with a container of Action Melt, snow melt product and a folded piece of paper that was placed under the open door. Additionally, the door failed to latch positively when it was exercised.

Based on record review, staff interview, and observation, the facility failed to ensure the monthly and annual tests of battery-powered emergency lights tests were performed and documented. This deficiency could affect all staff, residents and visitors in the facility.

Findings included:

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one half hours.

The maintenance logs were reviewed at the facility on 9/17/13. No documentation was available in the maintenance logs for the periodic testing of the emergency battery backup lighting located in the garage where the generator was located and in the maintenance office where the generator transfer switch was located.

The battery powered emergency light fixture located in the maintenance office (housed the generator transfer switch) was exercised at 1:52 p.m. on 9/17/13. The unit failed to illuminate. The unit lacked battery power. Staff member A verified that he didn't know he had to test these units monthly and once annually.

Based on record review and staff interview, the facility failed to ensure that on fire drills conducted between during all shifts within each quarter. This deficiency could affect more than a very limited amount of residents, staff and visitors in the facility.

Findings include:

The fire drill reports were reviewed at the facility at 8:55 a.m. on 9/17/13. The fire drills affect the entire facility and all residents. The facility utilized three shifts for the certified nurse aides. According to the logs:

a. For the October - December 2012 quarter, the night shift (11:00 a.m. to 7:00 a.m.) drill log was missing.

b. For the January - March 2013 quarter, the afternoon (3:00 p.m. to 11:00 p.m.) and the night shift drill logs were missing.

c. For the April - June 2013 quarter, the night shift (11:00 a.m. to 7:00 a.m.) drill log was missing.

On 9/17/13 at 3:30 p.m. staff member A stated he thought he only had to conduct two drills quarterly since the nurses worked 12 hour shifts.

Based on observations and staff interviews, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system. The deficiency could affect all residents, staff, and visitors in the building.

Findings include:

The building is of Type V (111) combustible construction which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 standards per NFPA 101 and Section 19.1.6.2.

1. The clinic was surveyed at 11:15 a.m. on 9/17/13. The closet located behind the entrance to the clinic, in the clinic waiting room, lacked automatic sprinkler coverage.

2. The secondary exit from the basement (Central Supply/Medical Records) was observed at 11:21 a.m. on 9/17/13. The canopy over the landing and the canopy over the stairs were not sprinklered. The canopy over the landing was wood construction. The canopy over the stairwell had a metal cover. Staff member A, who was accompanying the surveyor, said he did not know the construction type of the canopy, but it was a possibility that it was wood.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with the requirements in NFPA 13, 1999 Edition. This deficiency had the potential to affect more than a very limited number of residents, staff and the visitors in the building.

Findings include:

In accordance with NFPA 13 and Section 3-2.7.2, escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further, the code states in Annex A-3-2.7.2, the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. On 9/17/13 at 10:05 a.m., the walk-in cooler in the kitchen was observed. The escutcheon ring was loose around the automatic sprinkler pipe creating an annular space between the ring and the ceiling surface.

2. On 9/17/13 at 10:30 a.m., an annular space was observed between the sprinkler head where the sprinkler pipe shifted down and the escutcheon ring was not flush with the ceiling surface in front of the penthouse entry door in Zone 4.

3. On 9/17/13 at 10:57 a.m., an annular space was observed between the sprinkler head and the solid ceiling surface in the Server room where the ceiling appeared to be damaged around the escutcheon ring.

Based on observation and interviews, the facility failed to ensure baffle filters located in the kitchen hood were installed properly between washes per NFPA 96, 1998 Edition. This deficiency had the potential to affect a very limited amount of residents, staff, and visitors.

Findings include:

In accordance with NFPA 96 and Section 3-2.7, grease filters that require a specific orientation to drain grease shall be clearly so designated, or the hood shall be constructed so that filters cannot be installed in the wrong orientation.

The kitchen was observed on 9/17/13 at 10:03 a.m. The one of the three baffle filters (the middle one) located in the kitchen hood was installed in the wrong orientation and needed to be rotated 90 degrees so grease can be directed to the drip tray. The filters should be installed per manufacturers recommendations.

Based on observation, the facility failed to ensure that oxygen was stored safely in accordance with NFPA 99 Chapter 4 Gas and Vacuum Systems and specifically 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). This deficiency could affect more than a very limited number of residents and staff in the building.

Findings include:

Outside oxygen storage was observed at 2:05 p.m. on 9/17/13. The location contained approximately 50 E size, and 14 K size, and a number of D size oxygen cylinders. The storage was not locked in an enclosed space. Staff member A stated the shed behind the storage was built for the oxygen, but it became other storage.

Based on observations, the facility failed to ensure that smoke dampers interconnected to the facility fire alarm system closed upon the activation of the fire alarm system. This deficiency had potential to affect almost all of the residents, staff and visitors in two smoke compartments.

Findings include:

If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of Heating, Ventilation, and Air Conditioning (HVAC) systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity, including relays that cause the dampers to close and open upon activation and reset of the fire alarm system per section 3-9.5.2 of NFPA 72, 1999 Edition.

The smoke dampers were exercised between 10:15 a.m. and 10:28 a.m. on 9/17/13. All four of the dampers (two in the barrier wall in Timber Creek and two in Spring Creek) stayed opened when the fire alarms were activated in these two different smoke compartments.

Based on record review and staff interview, the facility failed to ensure weekly visual inspections completed on the generator were documented. This deficiency could affect all residents, staff, and visitors in the building.

Findings include:

Generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99 3.4.4.1.

The generator test and inspection reports were reviewed at the facility on 9/17/13 at 8:37 a.m. and later at 1:52 p.m. near the generator's location. The weekly inspection reports/logs for the generator were not available for review. Staff member A stated he did not document the weekly visual tests.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies have the potential to affect more than a limited number of residents, staff and visitors in the basement of the building.

Findings include:

In accordance with 240-4 of the NFPA 70 (1999 Edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 Edition) and previous interpretations from CMS (transmittal notice dated 3-30-99) extension cords or multiple adaptors used in health care shall be protected against over-current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS); one means is by providing surge strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.
The limited use of circuit breaker protected power strips is acceptable, provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

In accordance with NFPA 70 and Article 370-25, in completed installations, each box shall have a cover, faceplate, or fixture canopy.

1. The electrical junction box, found above the ceiling tiles at the 2-hour fire wall separation near the ER, had a missing cover at 10:14 a.m. 9/17/13.

2. A vending machine (Coke) was observed in Zone 4 near ER at 11:01 a.m. on 9/17/13. The unit was plugged into a power tap.

3. The administration office was observed at 1:24 p.m. on 9/17/13. Two power strips were plugged into each other under the receptionist's desk. Several equipment was plugged into the power taps.