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Based on observations and interview, the facility failed to maintain a Type II (III) construction type in 1 location of the facility by allowing a penetration in the ceiling to be present. This effects 1 smoke zone in the facility. The facility had a capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-19 at approximately 12:46 pm, revealed a pipe penetration (approximately 1/4 inch in size) located in the corridor wall of the Lab Air Handler Room.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain 1 set of smoke barrier doors to close properly. This affects 2 smoke zones. The facility had a capacity of 25 patients and census of 5 patients.

Findings include:

Observation and interview on 3-18-15 at approximately 1:49 pm, revealed the smoke barrier doors located near the Specialty Clinic Waiting Area failed to close and latch when tested.

Maintenance Staff A verified this observation at the time of the survey process.

(A)
Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated by allowing a door to this room to be non-compliant. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 1:18 pm, revealed the Gift Shop Storage Room door was equipped with a hollow core door, therefore not meeting the proper fire rating.

Maintenance Staff A verified this observation at the time of the survey process.


(B)
Based on observations and interview, the facility failed to maintain 3 hazardous room properly separated by allowing penetrations to be present. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15, between the hours of 11:08 am and 11:17 am revealed the following:

1. 2 pipe penetrations (approximately 3 inches each in size) located in the ceiling of the Housekeeping Supply Room. These penetrations were stuffed with ordinary fiberglass insulation.

2. A pipe penetration (approximately 2 inches each in size) located in the ceiling of the Purchasing Store Room. This penetration was stuffed with ordinary fiberglass insulation.

3. 4 pipe penetrations (approximately 3 inches each in size) located in the ceiling of the 1995 Mechanical Room. These penetrations were stuffed with ordinary fiberglass insulation.


Maintenance Staff A verified these observations at the time of the survey process.


(C)
Based on observations and interview, the facility failed to maintain 8 hazardous room properly separated by failing to ensure the doors to these rooms are equipped with an automatic self-closing device. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15, between the hours of 1:18 pm and 2:34 pm revealed the following hazardous rooms (larger than 50 square feet with combustible storage items) failed to be equipped with a door that has a self-closing device on it:

1. The door to Gift Shop Storage Room.
2. The door to Room #140.
3. The door to Room #141.
4. The door to the Dietary Storage Supply Room.
5. The door to the Patient Records Room (#168).
6. The door to Room #AD107.
7. The door to the Old O.R. Room (#171).
8. The door to Room #M225.

Maintenance Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide an approved exit discharge from 1 exit door by failing to clear away piles of leaves. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 revealed the Park Place Link exit discharge area was covered with a large pile of leaves.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide emergency lighting at 1 required exit discharge area. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 12:57 pm, revealed the absence of emergency lighting at the Park Place Link exit discharge area.

Maintenance Staff A verified this observation at the time of the survey process.

(A)
Based on record review and interview, the facility failed to provide documentation that the battery back-up emergency lighting system was being properly tested on a monthly basis. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Record review and interview on 3-19-15 at approximately 9:15 am, revealed the absence of the required 30 second monthly testing of the facilities battery back-up emergency lighting system.

Maintenance Staff A verified this observation at the time of the survey process.

(B)
Based on record review and interview, the facility failed to provide documentation that the battery back-up emergency lighting system was being properly tested on a annual basis. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Record review and interview on 3-19-15 at approximately 9:16 am, revealed the absence of the required 90 minute annual testing of the facilities battery back-up emergency lighting system.

Maintenance Staff A verified this observation at the time of the survey process.

C.
Based on observations and interview, the facility failed to maintain 1 emergency light unit is proper working order. The facility had a license capacity of 90 residents and a census of 46 residents.

Findings include:

Observations and interview on 3-18-15 at approximately 10:51 am, revealed the emergency light unit located in the Electrical Room failed to operate on battery back when tested.

Maintenance Staff A verified this observation at the time of the survey process.

(A)
Based on observations and interview, the facility failed to maintain 1 exit light properly illuminated at all times. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 10:40 am, revealed the exit light located in the Soiled Laundry Dock area failed to be illuminated at the time of inspection.

Staff Member A verified this observation at the time of the survey process.


(B)
Based on observations and interview, the facility failed to ensure that exit signs are properly located at required areas in the facility. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15, between the hours of 10:54 am and 10:55 am, revealed the absence of a required exit sign at the following locations:

1. Near the new elevator in the Basement.
2. Near the double doors, south of the new elevator in the Basement.

Staff Member A verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to conduct and document a fire drill on each nursing shift during each quarter year. The facility had a capacity of 25 patients and a census of 5 patients.

Findings include:

Record review and interview on 3-18-15 at approximately 9:30 am, revealed the facility failed to conduct and document a required fire drill during the 3rd nursing shift, during the 2nd quarter year of 2014.

Staff Member A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition by improperly locating a smoke detector. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 1:43 pm, revealed a smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling near the entrance to the Cafeteria.

Maintenance Staff A verified this observation during the survey process.

Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition by allowing a manual pull station to be obstructed. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 1:40 pm, revealed the manual pull station located in the dish wash area of the Kitchen was obstructed with storage items.

Maintenance Staff A verified this observation during the survey process.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 Edition by failing to properly document the required quarterly sprinkler inspections. The facility had a capacity of 25 patients and a census of 5 patients.

Findings include:

Record review and interview on 3-18-15 at approximately 10:02 am, revealed the facility failed to document a quarterly sprinkler inspection during the 1st quarter year of 2014.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by failing to have a Ground Fault Circuit Interrupter electrical outlet installed in a required area. The facility had a capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 10:38 am, revealed the absence of a required Ground Fault Circuit Interrupter (GFCI) electrical outlet located near the sink in the dirty side of the Central Sterilizing Room.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to have 3 Alcohol Based Hand Rub dispensers properly located in the facility. The facility has a capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15, between the hours of 1:10 pm and 1:34 pm revealed an Alcohol Based Hand Rub dispenser that was located above an electrical source (electrical outlet or light switch) in the following locations:

1. In the 1st Floor Trash Compactor entry area.
2. In Room #6 in the Ambulatory Surgery Area.
3. In Room #S33.

Maintenance Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to maintain a Type II (III) construction type in 1 location of the facility by allowing a penetration in the ceiling to be present. This effects 1 smoke zone in the facility. The facility had a capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-19 at approximately 12:46 pm, revealed a pipe penetration (approximately 1/4 inch in size) located in the corridor wall of the Lab Air Handler Room.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain 1 set of smoke barrier doors to close properly. This affects 2 smoke zones. The facility had a capacity of 25 patients and census of 5 patients.

Findings include:

Observation and interview on 3-18-15 at approximately 1:49 pm, revealed the smoke barrier doors located near the Specialty Clinic Waiting Area failed to close and latch when tested.

Maintenance Staff A verified this observation at the time of the survey process.

(A)
Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated by allowing a door to this room to be non-compliant. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 1:18 pm, revealed the Gift Shop Storage Room door was equipped with a hollow core door, therefore not meeting the proper fire rating.

Maintenance Staff A verified this observation at the time of the survey process.


(B)
Based on observations and interview, the facility failed to maintain 3 hazardous room properly separated by allowing penetrations to be present. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15, between the hours of 11:08 am and 11:17 am revealed the following:

1. 2 pipe penetrations (approximately 3 inches each in size) located in the ceiling of the Housekeeping Supply Room. These penetrations were stuffed with ordinary fiberglass insulation.

2. A pipe penetration (approximately 2 inches each in size) located in the ceiling of the Purchasing Store Room. This penetration was stuffed with ordinary fiberglass insulation.

3. 4 pipe penetrations (approximately 3 inches each in size) located in the ceiling of the 1995 Mechanical Room. These penetrations were stuffed with ordinary fiberglass insulation.


Maintenance Staff A verified these observations at the time of the survey process.


(C)
Based on observations and interview, the facility failed to maintain 8 hazardous room properly separated by failing to ensure the doors to these rooms are equipped with an automatic self-closing device. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15, between the hours of 1:18 pm and 2:34 pm revealed the following hazardous rooms (larger than 50 square feet with combustible storage items) failed to be equipped with a door that has a self-closing device on it:

1. The door to Gift Shop Storage Room.
2. The door to Room #140.
3. The door to Room #141.
4. The door to the Dietary Storage Supply Room.
5. The door to the Patient Records Room (#168).
6. The door to Room #AD107.
7. The door to the Old O.R. Room (#171).
8. The door to Room #M225.

Maintenance Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to provide an approved exit discharge from 1 exit door by failing to clear away piles of leaves. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 revealed the Park Place Link exit discharge area was covered with a large pile of leaves.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide emergency lighting at 1 required exit discharge area. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 12:57 pm, revealed the absence of emergency lighting at the Park Place Link exit discharge area.

Maintenance Staff A verified this observation at the time of the survey process.

(A)
Based on record review and interview, the facility failed to provide documentation that the battery back-up emergency lighting system was being properly tested on a monthly basis. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Record review and interview on 3-19-15 at approximately 9:15 am, revealed the absence of the required 30 second monthly testing of the facilities battery back-up emergency lighting system.

Maintenance Staff A verified this observation at the time of the survey process.

(B)
Based on record review and interview, the facility failed to provide documentation that the battery back-up emergency lighting system was being properly tested on a annual basis. The facility had a license capacity of 25 patients and a census of 5 patients.

Findings include:

Record review and interview on 3-19-15 at approximately 9:16 am, revealed the absence of the required 90 minute annual testing of the facilities battery back-up emergency lighting system.

Maintenance Staff A verified this observation at the time of the survey process.

C.
Based on observations and interview, the facility failed to maintain 1 emergency light unit is proper working order. The facility had a license capacity of 90 residents and a census of 46 residents.

Findings include:

Observations and interview on 3-18-15 at approximately 10:51 am, revealed the emergency light unit located in the Electrical Room failed to operate on battery back when tested.

Maintenance Staff A verified this observation at the time of the survey process.

(A)
Based on observations and interview, the facility failed to maintain 1 exit light properly illuminated at all times. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 10:40 am, revealed the exit light located in the Soiled Laundry Dock area failed to be illuminated at the time of inspection.

Staff Member A verified this observation at the time of the survey process.


(B)
Based on observations and interview, the facility failed to ensure that exit signs are properly located at required areas in the facility. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15, between the hours of 10:54 am and 10:55 am, revealed the absence of a required exit sign at the following locations:

1. Near the new elevator in the Basement.
2. Near the double doors, south of the new elevator in the Basement.

Staff Member A verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to conduct and document a fire drill on each nursing shift during each quarter year. The facility had a capacity of 25 patients and a census of 5 patients.

Findings include:

Record review and interview on 3-18-15 at approximately 9:30 am, revealed the facility failed to conduct and document a required fire drill during the 3rd nursing shift, during the 2nd quarter year of 2014.

Staff Member A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition by improperly locating a smoke detector. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 1:43 pm, revealed a smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling near the entrance to the Cafeteria.

Maintenance Staff A verified this observation during the survey process.

Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition by allowing a manual pull station to be obstructed. The facility had a license of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 1:40 pm, revealed the manual pull station located in the dish wash area of the Kitchen was obstructed with storage items.

Maintenance Staff A verified this observation during the survey process.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 Edition by failing to properly document the required quarterly sprinkler inspections. The facility had a capacity of 25 patients and a census of 5 patients.

Findings include:

Record review and interview on 3-18-15 at approximately 10:02 am, revealed the facility failed to document a quarterly sprinkler inspection during the 1st quarter year of 2014.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by failing to have a Ground Fault Circuit Interrupter electrical outlet installed in a required area. The facility had a capacity of 25 patients and a census of 5 patients.

Findings include:

Observations and interview on 3-18-15 at approximately 10:38 am, revealed the absence of a required Ground Fault Circuit Interrupter (GFCI) electrical outlet located near the sink in the dirty side of the Central Sterilizing Room.

Maintenance Staff A verified this observation at the time of the survey process.