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Based on observation and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the facility.

Findings include:

1. Observation on October 31, 2017, between 9:45 AM and 11:10 AM, revealed the facility lacked carbon monoxide alarms in the following locations:

a. 9:45 AM - The Boiler Room.
b. 10:00 AM - The Laundry Department.
c. 11:10 AM - The Dietary Department.

Exit interview with the facility administrator and facility representative #1 on October 31, 2017, between 11:30 AM and 11:40 AM, confirmed the lack of carbon monoxide alarms.

Based on observation and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the facility.

Findings include:

1. Observation on October 31, 2017, revealed the facility failed to receive approved Department of Health (DOH) plans prior to the major demolition work currently being done in rooms #108 and #110.

Exit interview with the facility administrator and facility representative #1 on October 31, 2017, between 11:30 AM and 11:40 AM, confirmed demolition work being done without approved plans.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in 1 instance, affecting 1 of 3 smoke compartments within the facility.

Findings include:

1. Observation on October 31, 2017, at 11:20 AM, revealed the recessed ceiling light fixture located in the corridor outside the Chapel lacked bonnet protection.

Exit interview with the facility administrator and facility representative #1 on October 31, 2017, between 11:30 AM and 11:40 AM, confirmed the light fixture lacked bonnet protection.

Based on observation and interview, it was determined the facility failed to maintain common wall doors, affecting 2 of 2 components within the facility.

Findings include:

1. Observation on October 31, 2017, at 10:55 AM, revealed the common wall doors between the 01 building and the 02 building could not close and latch when released from the hold open devices.

Exit interview with the facility administrator and facility representative #1 on October 31, 2017, between 11:30 AM and 11:40 AM, confirmed the doors could not close and latch.

Based on observation and interview, it was determined the facility failed to maintain sprinkler systems in one instance, affecting one of three smoke compartments within the facility.

Findings include:

1. Observation on October 31, 2017, at 10:00 AM, revealed the Draw room had a mix of quick response and standard sprinkler heads.

Exit interview with the facility administrator and facility representative #1 on October 31, 2017, between 11:30 AM and 11:40 AM, confirmed the mix of sprinkler heads.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls in one instance, affecting two of three smoke compartments within the facility.

Findings include:

1. Observation on October 31, 2017, at 10:15 AM, revealed unsealed penetrations around pipes located in the acute patient restroom.

Exit interview with the facility administrator and facility representative #1 on October 31, 2017, between 11:30 AM and 11:40 AM, confirmed the penetrations.

Based on documentation review and interview, it was determined the facility failed to maintain key components of the heating, ventilation and cooling (HVAC) system, affecting the entire facility.

Findings include:

1. Review of documentation on October 31, 2017, at 9:05 AM, revealed the facility lacked current records to support the required four-year testing and inspection of HVAC fire/smoke dampers.

Exit interview with the facility administrator and facility representative #1 on October 31, 2017, between 11:30 AM and 11:40 AM, confirmed the lack of documentation.

Based on documentation review, observation and interview, it was determined the facility failed to maintain generators in one instance, affecting three of three smoke compartments within the facility.

Findings include:

1. Review of documentation on October 31, 2017, at 11:05 AM, revealed the facility lacked documentation for the required weekly voltage testing of the emergency generators sealed battery.

Exit interview with the facility administrator and facility representative #1 on October 31, 2017, between 11:30 AM and 11:40 AM, confirmed the lack of documentation.