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Based on observation it was determined the facility failed to maintain the smoke/fire resistive rating of the nursing station wall.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, The nursing station is separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On June 3, 2015, the surveyor, accompanied by Director of Maintenance, observed that the wall behind the East entrance door to the nursing station had a hole, which was approximately 1 inch in diameter.

During the exit conference on May 3, 2015, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke."

Findings Include:

On June 3, 2015, the surveyor, accompanied by the Director of Maintenance observed the following corridor doors.

1. The door to the employee lounge was wedged open.
2. The clean side laundry room corridor door sticks to the floor when opened.

During the exit conference on June 3, 2015, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

The facility failed to protect patients from heat and smoke.

Based on observation it was determined that the facility failed to keep the laundry room dryer exhaust duct sealed.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 Utilities. "Utilities shall comply with the provisions of Section 9-1. Chapter 9, Section 9.1.1 "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 National Fuel Gas Code. National Fuel Gas Code, NFPA 54 Chapter 6, Section 6.4 Clothes Dryers Section 6.4.5 Exhaust ducts for type 2 clothes dryers shall be constructed of sheet metal or other noncombustible material. Such ducts shall be equivalent in strength and corrosion resistance to ducts made of galvanized sheet steel not less than 0.0195 in. (0.5 mm) thick."

On June 3, 2015, the surveyor, accompanied by the Director of Maintenance, observed the dryer duct in the laundry room. The duct tape was separated from the duct exposing the laundry room to exhaust fumes.

During the exit conference on June 3, 2015, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failing to insure proper maintenance of the exhaust duct system could lead to a possible fire which could cause harm to patients.

Based on observation it was determined that the facility failed to assure that all parts of the facility were provided sprinkler system coverage.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-5.6, " The clearance between the deflector and the top of storage shall be 18 in. or greater."

Findings Include:

On June 3, 2015, the surveyor, accompanied by the Director of Maintenance, observed the office supply storage room. Storage was within 5 inches of the sprinkler head.

During the exit conference on June 3, 2015, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads will result in injury to patients and staff.

Based on observation it was determined that the facility failed to provide signs indicating empty and full medical gas cylinders.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in Accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly."

Findings Include:

On June 3, 2015, the surveyor, accompanied by the Maintenance Director, observed the medical gas storage room. There are two racks of E tank cylinders which are not marked empty or full.

During the exit conference on June 3, 2015, the above findings were again acknowledged by the Administrator and the Director of Maintenance.

In an emergency, patients would be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.