HospitalInspections.org

Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the doors on the Lab storage room #LL-626A and the Lab Draw room #1-226 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 11/3/10 at approximately 11:19am, by observation and interview of the Director of Facilities/Environmental Services, the door on the Lab storage room #LL-626A failed to latch properly when tested. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:48am, by observation and interview of the Director of Facilities/Environmental Services, the door on the Lab Draw room #1-226 failed to latch properly when tested. This finding was verified with the Director of Facilities/Environmental Services 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 doors on the Lab storage room #LL-626A and the Lab Draw room #1-226 in accordance with the LSC, section 19.3.6.3.3. Findings Include:

On 11/3/10 at approximately 11:19am, by observation and interview of the Director of Facilities/Environmental Services, the door on the Lab storage room #LL-626A failed to latch properly when tested. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:48am, by observation and interview of the Director of Facilities/Environmental Services, the door on the Lab Draw room #1-226 failed to latch properly when tested. This finding was verified with the Director of Facilities/Environmental Services 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 barrier walls in the boiler room on the lower level, mechanical room #5, kitchen wall at the Ansul system, telephone room (LL-602), storage room #LL-630, corridor wall at the Dining Room, smoke barrier wall at the Dining Room, smoke barrier wall first floor at room #1-402, smoke barrier wall second floor at room #212 and soiled utility room (2-216) in accordance with the LSC, section 19.3.7.3.

Findings Include:

On 11/3/10 at approximately 10:49am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the boiler room on the lower level failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:00am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in mechanical room #5 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:05am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the kitchen at the Ansul system failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:11am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the telephone room (LL-602) failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:21am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the storage room (LL-630) failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:31am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the corridor wall at the Dining Room failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:41am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall at the Dining Room failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:45am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall on the first floor at room #1-402 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:45pm, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall on the second floor at room #212 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:51pm, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the soiled utility room #2-126 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services 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 barrier walls in the boiler room on the lower level, mechanical room #5, kitchen wall at the Ansul system, telephone room (LL-602), storage room #LL-630, corridor wall at the Dining Room, smoke barrier wall at the Dining Room, smoke barrier wall first floor at room #1-402, smoke barrier wall second floor at room #212 and soiled utility room (2-216) 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 11/3/10 at approximately 10:49am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the boiler room on the lower level failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:00am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in mechanical room #5 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:05am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the kitchen at the Ansul system failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:11am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the telephone room (LL-602) failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:21am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the storage room (LL-630) failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:31am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the corridor wall at the Dining Room failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:41am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall at the Dining Room failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:45am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall on the first floor at room #1-402 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:45pm, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall on the second floor at room #212 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:51pm, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the soiled utility room #2-126 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to provide and maintain the vertical opening protection of exits required by the LSC, section 19.3.7.5 by having rating labels painted on rated doors/frames on the smoke barrier doors at room #LL-620, smoke barrier doors at the Dining Room, smoke barrier doors at room #1-402, smoke barrier doors at room #1-604, smoke barrier doors at room #2-132 and smoke barrier door frame at room #212.

Findings Include:

On 11/3/10 at approximately 11:25am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #LL-620 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:42am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at Dining Room was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:46am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #1-402 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:54am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #1-604 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:45pm, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #2-132 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:49pm, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #212 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to provide and maintain the vertical opening protection of exits required by the LSC, section 19.3.1.1 by having rating labels painted on rated doors/frames in the maintenance shop, exit door at maintenance shop, clean linen room #LL-820, soiled linen room #LL-816, Lab storage room #LL-626A, storage room #LL-630.

Findings Include:

On 11/3/10 at approximately 10:55am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the Maintenance Shop was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 10:57am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the exit door at the maintenance shop was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 10:59am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the clean linen room #LL-820 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:02am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the soiled linen room #LL-816 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:18am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the Lab storage room #LL-626A was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:22am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the storage room #LL-630 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

Based upon record review and staff interview it was determined that the facility failed to conduct fire drills at unexpected times under varying conditions at least quarterly in accordance with the LSC, section 19.7.1.2 by conducting fire drills during shift change of Third and First shifts for the 2nd Quarter of 2010.

Findings Include:

On 11/3/10 at approximately 10:11am, during record review and interview of the Director of Facilities/Environmental Services, the facility was conducting and documenting required fire drills at shift change for Third and First shifts for the 2nd Quarter of 2010. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.
Based upon record review and staff interview it was determined that the facility failed to conduct fire drills at unexpected times under varying conditions at least quarterly in accordance with the LSC, section 19.7.1.2 by conducting fire drills during shift change of Third and First shifts for the 2nd Quarter of 2010. This deficient practice could affect all occupants including residents, staff and visitors. Findings Include:

On 11/3/10 at approximately 10:11am, during record review and interview of the Director of Facilities/Environmental Services, the facility was conducting and documenting required fire drills at shift change for Third and First shifts for the 2nd Quarter of 2010. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that the fire suppression system for the facility was inspected and tested in accordance with the LSC, section 19.3.5 by failing to remove wires that were attached to the sprinkler pipe in the shipping room on the lower level and wire attached to the sprinkler pipe in the Med Gas storage room on the lower level.

Findings Include:

On 11/3/10 at approximately 11:35am, by observation and interview of the Director of Facilities/Environmental Services, the facility failed to remove wires that were attached to the sprinkler pipe in the shipping room on the lower level. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:37am, by observation and interview of the Director of Facilities/Environmental Services, the facility failed to remove wires that were attached to the sprinkler pipe in the Med Gas storage room on the lower level. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.
Based upon observation and staff interview, it was determined that the facility failed to ensure that the fire suppression system for the facility was inspected and tested in accordance with the LSC, section 19.3.5 by failing to remove wires that were attached to the sprinkler pipe in the shipping room on the lower level and wire attached to the sprinkler pipe in the Med Gas storage room on the lower level. Findings Include:

On 11/3/10 at approximately 11:35am, by observation and interview of the Director of Facilities/Environmental Services, the facility failed to remove wires that were attached to the sprinkler pipe in the shipping room on the lower level. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:37am, by observation and interview of the Director of Facilities/Environmental Services, the facility failed to remove wires that were attached to the sprinkler pipe in the Med Gas storage room on the lower level. This finding was verified with the Director of Facilities/Environmental Services 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 doors on the Lab storage room #LL-626A and the Lab Draw room #1-226 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 11/3/10 at approximately 11:19am, by observation and interview of the Director of Facilities/Environmental Services, the door on the Lab storage room #LL-626A failed to latch properly when tested. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:48am, by observation and interview of the Director of Facilities/Environmental Services, the door on the Lab Draw room #1-226 failed to latch properly when tested. This finding was verified with the Director of Facilities/Environmental Services 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 doors on the Lab storage room #LL-626A and the Lab Draw room #1-226 in accordance with the LSC, section 19.3.6.3.3. Findings Include:

On 11/3/10 at approximately 11:19am, by observation and interview of the Director of Facilities/Environmental Services, the door on the Lab storage room #LL-626A failed to latch properly when tested. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:48am, by observation and interview of the Director of Facilities/Environmental Services, the door on the Lab Draw room #1-226 failed to latch properly when tested. This finding was verified with the Director of Facilities/Environmental Services 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 barrier walls in the boiler room on the lower level, mechanical room #5, kitchen wall at the Ansul system, telephone room (LL-602), storage room #LL-630, corridor wall at the Dining Room, smoke barrier wall at the Dining Room, smoke barrier wall first floor at room #1-402, smoke barrier wall second floor at room #212 and soiled utility room (2-216) in accordance with the LSC, section 19.3.7.3.

Findings Include:

On 11/3/10 at approximately 10:49am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the boiler room on the lower level failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:00am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in mechanical room #5 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:05am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the kitchen at the Ansul system failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:11am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the telephone room (LL-602) failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:21am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the storage room (LL-630) failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:31am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the corridor wall at the Dining Room failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:41am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall at the Dining Room failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:45am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall on the first floor at room #1-402 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:45pm, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall on the second floor at room #212 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:51pm, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the soiled utility room #2-126 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services 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 barrier walls in the boiler room on the lower level, mechanical room #5, kitchen wall at the Ansul system, telephone room (LL-602), storage room #LL-630, corridor wall at the Dining Room, smoke barrier wall at the Dining Room, smoke barrier wall first floor at room #1-402, smoke barrier wall second floor at room #212 and soiled utility room (2-216) 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 11/3/10 at approximately 10:49am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the boiler room on the lower level failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:00am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in mechanical room #5 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:05am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the kitchen at the Ansul system failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:11am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the telephone room (LL-602) failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:21am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the storage room (LL-630) failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:31am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the corridor wall at the Dining Room failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:41am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall at the Dining Room failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:45am, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall on the first floor at room #1-402 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:45pm, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall on the second floor at room #212 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:51pm, by observation and interview of the Director of Facilities/Environmental Services, penetrations of the smoke barrier wall in the soiled utility room #2-126 failed to be properly sealed. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to provide and maintain the vertical opening protection of exits required by the LSC, section 19.3.7.5 by having rating labels painted on rated doors/frames on the smoke barrier doors at room #LL-620, smoke barrier doors at the Dining Room, smoke barrier doors at room #1-402, smoke barrier doors at room #1-604, smoke barrier doors at room #2-132 and smoke barrier door frame at room #212.

Findings Include:

On 11/3/10 at approximately 11:25am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #LL-620 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:42am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at Dining Room was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:46am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #1-402 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:54am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #1-604 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:45pm, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #2-132 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 12:49pm, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the smoke barrier wall at room #212 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to provide and maintain the vertical opening protection of exits required by the LSC, section 19.3.1.1 by having rating labels painted on rated doors/frames in the maintenance shop, exit door at maintenance shop, clean linen room #LL-820, soiled linen room #LL-816, Lab storage room #LL-626A, storage room #LL-630.

Findings Include:

On 11/3/10 at approximately 10:55am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the Maintenance Shop was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 10:57am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the exit door at the maintenance shop was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 10:59am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the clean linen room #LL-820 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:02am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the soiled linen room #LL-816 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:18am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the Lab storage room #LL-626A was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:22am, by observation and interview of the Director of Facilities/Environmental Services the label on the rated door/frame to the storage room #LL-630 was painted and the fire resistance rating of the door/frame could not be determined. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

Based upon record review and staff interview it was determined that the facility failed to conduct fire drills at unexpected times under varying conditions at least quarterly in accordance with the LSC, section 19.7.1.2 by conducting fire drills during shift change of Third and First shifts for the 2nd Quarter of 2010.

Findings Include:

On 11/3/10 at approximately 10:11am, during record review and interview of the Director of Facilities/Environmental Services, the facility was conducting and documenting required fire drills at shift change for Third and First shifts for the 2nd Quarter of 2010. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.
Based upon record review and staff interview it was determined that the facility failed to conduct fire drills at unexpected times under varying conditions at least quarterly in accordance with the LSC, section 19.7.1.2 by conducting fire drills during shift change of Third and First shifts for the 2nd Quarter of 2010. This deficient practice could affect all occupants including residents, staff and visitors. Findings Include:

On 11/3/10 at approximately 10:11am, during record review and interview of the Director of Facilities/Environmental Services, the facility was conducting and documenting required fire drills at shift change for Third and First shifts for the 2nd Quarter of 2010. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that the fire suppression system for the facility was inspected and tested in accordance with the LSC, section 19.3.5 by failing to remove wires that were attached to the sprinkler pipe in the shipping room on the lower level and wire attached to the sprinkler pipe in the Med Gas storage room on the lower level.

Findings Include:

On 11/3/10 at approximately 11:35am, by observation and interview of the Director of Facilities/Environmental Services, the facility failed to remove wires that were attached to the sprinkler pipe in the shipping room on the lower level. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:37am, by observation and interview of the Director of Facilities/Environmental Services, the facility failed to remove wires that were attached to the sprinkler pipe in the Med Gas storage room on the lower level. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.
Based upon observation and staff interview, it was determined that the facility failed to ensure that the fire suppression system for the facility was inspected and tested in accordance with the LSC, section 19.3.5 by failing to remove wires that were attached to the sprinkler pipe in the shipping room on the lower level and wire attached to the sprinkler pipe in the Med Gas storage room on the lower level. Findings Include:

On 11/3/10 at approximately 11:35am, by observation and interview of the Director of Facilities/Environmental Services, the facility failed to remove wires that were attached to the sprinkler pipe in the shipping room on the lower level. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.

On 11/3/10 at approximately 11:37am, by observation and interview of the Director of Facilities/Environmental Services, the facility failed to remove wires that were attached to the sprinkler pipe in the Med Gas storage room on the lower level. This finding was verified with the Director of Facilities/Environmental Services at the time of discovery.