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Based on the surveyor's observations of August 15, 2011, the facility failed to ensure that all corridor doors were maintained to allow the doors to close to positive latching.

Findings include:

At 12:53 p.m. in patient room #6, an attempt was made to close the corridor door. The vertical outer edge of the door became stuck in the door frame when an attempt was made to close the door. This problem prevented the door from closing to positive latching.

Based on observations made during a tour of the building on August 15, 2011, the surveyor determined that the facility failed to ensure that all self closing corridor doors at storage room locations were adequately maintained.

Findings include:

In accordance with Section 19.3.6.3.2 of NFPA 101, 2000 Edition; corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

At 10:27 a.m., the corridor door to the Records Room in the south west corridor of the building was tested. The door would not automatically close to positive latching when the door was released by the surveyor.

Based on the surveyor's observations of August 15, 2011, the surveyor determined that not all hazardous areas (when required) were separated from other areas by one hour construction and/or walls (includes ceilings) were being maintained to prevent the passage of smoke from any hazardous area.

Findings include:

1. At 11:01 a.m., the surveyor inspected the Laundry located on the southwest corridor of the building. Above a washer, a ventilation duct passes through the ceiling. The open seam at the ceiling penetration caused by the duct needs to be sealed with an acceptable fire stop material.

2. At 10:27 a.m., the surveyor inspected the Records Room located next to the Laundry on the southwest corridor of the building. Where the partition of the room met the ceiling, a one inch section of conduit was in an unsealed penetration. The penetration had not been sealed with an acceptable fire stop material.

3. At approximately 1:24 p.m., the surveyor inspected the Boiler Room. Six copper sections of piping passed through the brick wall at the level of the ceiling. The foam product used to seal the penetrations caused by the piping was not an acceptable fire stop material. All penetrations at this location need to be sealed with an acceptable fire stop material.

Based on observations made on August 15, 2011, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

Findings include:

The building is of Type V (111) construction that requires that it be protected throughout by an approved automatic sprinkler system meeting the standards of NFPA 13, 1999 Edition. During the course of the survey conducted on August 15,16& 18, 2011, only a portion of the building was observed to be provided with sprinkler protection. The sprinkler protection in place was found to be in the Laundry, Boiler Room, Records Room and Staff Lounge.

Based on observations which were made on August 15, 2011, it was determined that the facility failed to ensure that all of the smoking requirements per Section 19.7.4 (4) of NFPA 101, 2000 Edition, were being followed.

Findings include :

At 10:22 a.m., the surveyor observed the staff smoking area located outside the exit door at the end of the southwest corridor of the building. When the surveyor examined the smoking area, it was determined there was no acceptable self-closing metal container as required.

Based on observations made by the surveyor on August 15, 2011, the determination was made that not all requirements of NFPA 99, 1999 Edition, were being followed by the facility.

Findings include:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99; freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

At 11:16 a.m., the oxygen storage room on the southwest corridor of the building was inspected by the surveyor. Two "E" size cylinders of oxygen were observed to be stored on the floor in one corner of the room. The cylinders were not held in place by a chain or other acceptable means to keep the cylinders secure.

Based on observations of August 15, 2011, the facility failed to store cooking devices away from the building.

In accordance with 3-2.2.2 of NFPA 58 (Liquefied Petroleum Gas Code 1998 Edition) portable LPG tanks used for such items as barbecues shall be located at least 3 feet from any building opening and at least 5 feet in any direction from an exterior source of ignition, direct-vent appliances or mechanical ventilation air intakes.

Findings include:

The location of the smoking area outside and at the end of the southwest wing, was observed by the surveyor at 10:22 a.m. A barbecue unit was stored directly against the exterior wall of the building. Cooking devices such as barbecues containing combustible gas (propane) must be stored at least 5 feet from a building which may be an exterior source of ignition.

Based on observations made on August 16, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition, NFPA 99, 1999 Edition, or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with NFPA 101 and Section 39.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 and interpretations from CMS.

At 1:20 p.m., an electrical multi-adaptor was in use for office equipment in the receptionist's office located by the waiting room.

Based on the surveyor's observations of August 15, 2011, the facility failed to ensure that all corridor doors were maintained to allow the doors to close to positive latching.

Findings include:

At 12:53 p.m. in patient room #6, an attempt was made to close the corridor door. The vertical outer edge of the door became stuck in the door frame when an attempt was made to close the door. This problem prevented the door from closing to positive latching.

Based on observations made during a tour of the building on August 15, 2011, the surveyor determined that the facility failed to ensure that all self closing corridor doors at storage room locations were adequately maintained.

Findings include:

In accordance with Section 19.3.6.3.2 of NFPA 101, 2000 Edition; corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

At 10:27 a.m., the corridor door to the Records Room in the south west corridor of the building was tested. The door would not automatically close to positive latching when the door was released by the surveyor.

Based on the surveyor's observations of August 15, 2011, the surveyor determined that not all hazardous areas (when required) were separated from other areas by one hour construction and/or walls (includes ceilings) were being maintained to prevent the passage of smoke from any hazardous area.

Findings include:

1. At 11:01 a.m., the surveyor inspected the Laundry located on the southwest corridor of the building. Above a washer, a ventilation duct passes through the ceiling. The open seam at the ceiling penetration caused by the duct needs to be sealed with an acceptable fire stop material.

2. At 10:27 a.m., the surveyor inspected the Records Room located next to the Laundry on the southwest corridor of the building. Where the partition of the room met the ceiling, a one inch section of conduit was in an unsealed penetration. The penetration had not been sealed with an acceptable fire stop material.

3. At approximately 1:24 p.m., the surveyor inspected the Boiler Room. Six copper sections of piping passed through the brick wall at the level of the ceiling. The foam product used to seal the penetrations caused by the piping was not an acceptable fire stop material. All penetrations at this location need to be sealed with an acceptable fire stop material.

Based on observations made on August 15, 2011, the facility failed to provide for complete coverage of the building by an approved automatic sprinkler system.

Findings include:

The building is of Type V (111) construction that requires that it be protected throughout by an approved automatic sprinkler system meeting the standards of NFPA 13, 1999 Edition. During the course of the survey conducted on August 15,16& 18, 2011, only a portion of the building was observed to be provided with sprinkler protection. The sprinkler protection in place was found to be in the Laundry, Boiler Room, Records Room and Staff Lounge.

Based on observations which were made on August 15, 2011, it was determined that the facility failed to ensure that all of the smoking requirements per Section 19.7.4 (4) of NFPA 101, 2000 Edition, were being followed.

Findings include :

At 10:22 a.m., the surveyor observed the staff smoking area located outside the exit door at the end of the southwest corridor of the building. When the surveyor examined the smoking area, it was determined there was no acceptable self-closing metal container as required.

Based on observations made by the surveyor on August 15, 2011, the determination was made that not all requirements of NFPA 99, 1999 Edition, were being followed by the facility.

Findings include:

In accordance with 8-3.1.22.2(h) and 4-3.5.2.1(b27) of NFPA 99; freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

At 11:16 a.m., the oxygen storage room on the southwest corridor of the building was inspected by the surveyor. Two "E" size cylinders of oxygen were observed to be stored on the floor in one corner of the room. The cylinders were not held in place by a chain or other acceptable means to keep the cylinders secure.

Based on observations of August 15, 2011, the facility failed to store cooking devices away from the building.

In accordance with 3-2.2.2 of NFPA 58 (Liquefied Petroleum Gas Code 1998 Edition) portable LPG tanks used for such items as barbecues shall be located at least 3 feet from any building opening and at least 5 feet in any direction from an exterior source of ignition, direct-vent appliances or mechanical ventilation air intakes.

Findings include:

The location of the smoking area outside and at the end of the southwest wing, was observed by the surveyor at 10:22 a.m. A barbecue unit was stored directly against the exterior wall of the building. Cooking devices such as barbecues containing combustible gas (propane) must be stored at least 5 feet from a building which may be an exterior source of ignition.

Based on observations made on August 16, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition, NFPA 99, 1999 Edition, or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with NFPA 101 and Section 39.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 and interpretations from CMS.

At 1:20 p.m., an electrical multi-adaptor was in use for office equipment in the receptionist's office located by the waiting room.