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Based on observation it was determined the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings Include:

On September 2, 2014, the surveyor, accompanied by the Director of Hospitality observed the double smoke barrier doors in the East/West, North wing by medical staff have a gap greater than 1/4 inch and are not smoke tight.

During the exit conference on September 2, 2014, the above findings were again acknowledged by the CEO and the director of Hospitality.

Failure to maintain the smoke seals on corridor doors will allow smoke to contaminate smoke zones not directly effected by the fire which will cause harm to patients and staff.

Based on observation it was determined the facility did not maintain the integrity, smoke resistance, of walls in hazardous areas, and failed to provide a self-closing or an automatic-closing device in a hazardous area.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.2.1, "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 18.3.5.4. 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.

Findings include:

On September 2, 2014, the surveyor, accompanied by the Director of Hospitality observed unsealed pipe chase holes, holes in walls or ceilings and no door closing device in the following locations:

1. 2025 Physical Therapy storage room, no door closing device, room contains flammables and combustibles.
2. Material Management IT closet, nine penetrations, not smoke tight.
3. 1148 A, SPD room, six penetrations, not smoke tight.
4. Kitchen, janitor closet, no door closing device, door held open by an impediment, and the room contains chemicals.
5. OR equipment storage, door tested three of three times and will not positively latch.

During the exit conference on September 2, 2014, the above findings were again acknowledged by the CEO and the director of Hospitality.

The pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to residents/patients.
Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to residents in time of a fire.

Based on observation, staff interview and policy review it was determined the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.1 and Section 18.2.3.3 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On September 2, 2014, the surveyor, accompanied by the Director of Hospitality observed storage of three each hospital beds in the North and South corridors which exit East/West. Four of four exits are obstructed and measured eight feet reduced to four feet five inches.
The facilities Fire Plan does not discuss the removal of wheeled equipment from the exit corridors.

The Supervisor staff member interviewed stated she could push beds side by side in the corridor and she does not clear the corridor during Fire Drills.

During the exit conference on September 2, 2014, the above findings were again acknowledged by the CEO and the director of Hospitality.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation it was determined the facility failed to maintain the installed automatic sprinklers. The facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." . Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Installation of Sprinkler Systems, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Chapter 2, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation."

NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On September 2, 2014, the surveyor, accompanied by the Director of Hospitality observed the following sprinklers and escutcheon plates.

1. E 203, one of two sprinklers covered with spackle.
2. Across from OR three, missing escutcheon plate.
3. Kitchen, three of eleven sprinklers, lint.

During the exit conference on September 2, 2014, the above findings were again acknowledged by the CEO and the director of Hospitality.

Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Lint on the head or a leaking sprinkler head could slow that response or disable the sprinkler head. This will cause harm to patients by allowing the fire to grow to a size uncontrollable by the remaining sprinkler heads.

Based on observation and staff interview it was determined the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18-3.2.6, "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On September 2, 2014, the surveyor, accompanied by the Director of Hospitality observed the kitchen exhaust system hood, filters and grease drip tray areas, seven of seven filters have an excessive amount of grease buildup and the drip tray was 1/3 full. Staff cleans the filters three times a week.

During the exit conference on September 2, 2014, the above findings were again acknowledged by the CEO and the director of Hospitality.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on observation, it was determined the facility failed to provide a medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, "Health Care Facilities", Chapter 4, Section 4-5.1.1.2 "Storage Requirements (Location, Construction, Arrangement.) Section 4-5.1.1.2 (b) 5 "Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials." Section 4-5.1.1.2 (b) 7 "Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen..."

Findings include:

On September 2, 2014, the surveyor, accompanied by the Director of Hospitality observed the Resp. Therapy storage room. (2054) Four empty E O2 bottles and three full E O2 bottles are stored within five feet of combustibles and next to a 110 electrical outlet.

During the exit conference on September 2, 2014, the above findings were again acknowledged by the CEO and the director of Hospitality.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the residents.

Based on document review and staff interview it was determined the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

On September 2, 2014, the surveyor, accompanied by the Director of Hospitality and staff reviewed the generator test records.

1. Fifteen of twenty monthly load transfers were documented greater than the required 10 seconds after loss of normal power.
2. Three of twenty required monthly 30 minute run times were less than the required 30 minutes.

The documentation reviewed was from January 2013 to August 2014.

During the exit conference on September 2, 2014, the above findings were again acknowledged by the CEO and the director of Hospitality.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during lighting system failures.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On September 2, 2014, the surveyor, accompanied by the Director of Hospitality observed a refrigerator and microwave plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the Material Management department.

During the exit conference on September 2, 2014, the above findings were again acknowledged by the CEO and the director of Hospitality.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.