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Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the Nurse Charting Units on the walls throughout the facility in accordance with the LSC, section 19.3.6.1 and 19.3.6.2.1. This deficient practice could potentially affect all occupants including residents, staff and visitors.

Findings Include:

On 10/9/12 between the hours of 9:30am and 3:00pm, by observation and interview of the Safety & Security Manager the facility failed to maintain Nurse Charting Units throughout the facility. This finding was verified with the Safety & Security Manager 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 door on the soiled utility room in surgery, janitor closet in the kitchen and the door on the Transfer Center on the first floor in accordance with the LSC, section 19.3.6.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 10/9/12 at approximately 12:55pm, by observation and interview of the Safety & Security Manager, the door on the soiled utility room in surgery failed to properly close and latch when tested. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 1:30pm, by observation and interview of the Safety & Security Manager, the door on the janitor closet in the kitchen failed to properly close and latch when tested. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 1:45pm, by observation and interview of the Safety & Security Manager, the door on the Transfer Center on the first floor failed to properly close and latch when tested. This finding was verified with the Safety & Security Manager 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 on the second floor at the linen receiving room, janitor closet on 7South at the elevator, janitor closet on 6North, and the communication closet on 5North in accordance with the LSC, section 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 10/8/12 at approximately 2:10pm, by observation and interview of the Safety & Security Manager penetrations of the smoke barrier wall on the second floor at the linen receiving room failed to be properly sealed. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 9:58am, by observation and interview of the Safety & Security Manager penetrations of the smoke barrier wall in the janitor closet on 7South at the elevator failed to be properly sealed. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 10:25am, by observation and interview of the Safety & Security Manager penetrations of the smoke barrier wall in the janitor closet on 6North failed to be properly sealed. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 10:49am, by observation and interview of the Safety & Security Manager penetrations of the smoke barrier wall in the communication closet on 5North failed to be properly sealed. This finding was verified with the Safety & Security Manager at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to conduct fire drills for third shift at varying times throughout the year in accordance with the LSC, section 19.7.1.2. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 10/8/12 at approximately 10:30am, during record review and interview of the Safety & Security Manager the facility failed to document fire drills for third shift at varying times throughout the year. This finding was verified with the Safety & Security Manager at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to properly installed Alcohol Based Hand Rub (ABHR) containers in the soiled utility room in surgery in accordance with the LSC, section 19.3.2.7. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 10/9/12 at approximately 12:56pm, by observation and interview of the Safety & Security Manager the facility failed to properly install an Alcohol Based Hand Rub (ABHR) container in the soiled utility room in surgery. This finding was verified with the Safety & Security Manager 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 Nurse Charting Units on the walls throughout the facility in accordance with the LSC, section 19.3.6.1 and 19.3.6.2.1. This deficient practice could potentially affect all occupants including residents, staff and visitors.

Findings Include:

On 10/9/12 between the hours of 9:30am and 3:00pm, by observation and interview of the Safety & Security Manager the facility failed to maintain Nurse Charting Units throughout the facility. This finding was verified with the Safety & Security Manager 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 door on the soiled utility room in surgery, janitor closet in the kitchen and the door on the Transfer Center on the first floor in accordance with the LSC, section 19.3.6.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 10/9/12 at approximately 12:55pm, by observation and interview of the Safety & Security Manager, the door on the soiled utility room in surgery failed to properly close and latch when tested. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 1:30pm, by observation and interview of the Safety & Security Manager, the door on the janitor closet in the kitchen failed to properly close and latch when tested. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 1:45pm, by observation and interview of the Safety & Security Manager, the door on the Transfer Center on the first floor failed to properly close and latch when tested. This finding was verified with the Safety & Security Manager 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 on the second floor at the linen receiving room, janitor closet on 7South at the elevator, janitor closet on 6North, and the communication closet on 5North in accordance with the LSC, section 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 10/8/12 at approximately 2:10pm, by observation and interview of the Safety & Security Manager penetrations of the smoke barrier wall on the second floor at the linen receiving room failed to be properly sealed. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 9:58am, by observation and interview of the Safety & Security Manager penetrations of the smoke barrier wall in the janitor closet on 7South at the elevator failed to be properly sealed. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 10:25am, by observation and interview of the Safety & Security Manager penetrations of the smoke barrier wall in the janitor closet on 6North failed to be properly sealed. This finding was verified with the Safety & Security Manager at the time of discovery.

On 10/9/12 at approximately 10:49am, by observation and interview of the Safety & Security Manager penetrations of the smoke barrier wall in the communication closet on 5North failed to be properly sealed. This finding was verified with the Safety & Security Manager at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to conduct fire drills for third shift at varying times throughout the year in accordance with the LSC, section 19.7.1.2. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 10/8/12 at approximately 10:30am, during record review and interview of the Safety & Security Manager the facility failed to document fire drills for third shift at varying times throughout the year. This finding was verified with the Safety & Security Manager at the time of discovery.