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Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the door on the X-Ray Reading Room, Med Room at room #114, Tub Room at room #114, OR/Scope Area and janitor closet in the Surgery Corridor 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 5/8/13 at approximately 12:00pm, by observation and interview of the Maintenance Supervisor the door on the X-Ray Reading Room failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:13pm, by observation and interview of the Maintenance Supervisor the door on the Med Room at room #114 failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:14pm, by observation and interview of the Maintenance Supervisor the door on the Tub Room at room #114 failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:30pm, by observation and interview of the Maintenance Supervisor the door on the OR/Scope Area failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:33pm, by observation and interview of the Maintenance Supervisor the door on the janitor closet in the Surgery Corridor failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor 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 wall in the Old Incinerator Room, basement at the linen room, elevator control room in the basement, southend of the Tunnel, smoke barrier wall in the Emergency Department Hallway and the smoke barrier wall at room #109 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 5/8/13 at approximately 11:20am, by observation and interview of the Maintenance Supervisor penetrations in the Old Incinerator Room failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 11:26am, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall in the basement at the linen room failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 11:31am, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall in the elevator control room in the basement failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 11:35am, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall at the south end of the tunnel failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:05pm, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall in the Emergency Department Hallway failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:11pm, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall at room #109 failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, the facility failed to provide documentation that the automatic sprinkler system for the facility is maintained and/or tested in accordance with the LSC, section 19.7.6, 4.6.12, 9.7.5. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 5/8/13 at approximately 10:47am, during record review and interview of the Maintenance Supervisor the facility failed to provide documentation of the required annual test of the facilities sprinkler system. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that the facilities cooking facilities were inspected and documented in accordance with the LSC, section 19.3.2.6. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/8/13 at approximately 10:47am, during record review and interview of the Maintenance Supervisor the facility failed to provide documentation of the required semi-annual testing of the facilities cooking equipment. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure the generator was exercised under load for the months of March and April of 2013 and performance of a FULL LOAD BANK test in accordance with NFPA 99, section 3.4.4.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 5/8/13 at approximately 10:33am, during record review and interview of the Maintenance Supervisor the facility failed to properly document the required monthly 30-minute load test of the facilities generator. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 10:34am, during record review and interview of the Maintenance Supervisor the facility failed to provide documentation of the required FULL LOAD BANK test for the facilities generator. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure electrical wiring to be in accordance with NFPA 70, National Electrical Code, section 9.1.2 by having open electrical wires in the mechanical room in the basement, open electrical junction box above the ceiling at the smoke barrier wall in the Emergency Department hallway, open electrical junction box above the ceiling at the smoke barrier wall at X-Ray and having open wiring in the ceiling at the smoke barrier wall to Surgery. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/8/13 at approximately 11:22am, by observation and interview of the Maintenance Supervisor the facility failed to properly cover open electrical wires in the mechanical room in the basement. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:05pm, by observation and interview of the Maintenance Supervisor the facility failed to properly cover an open electrical junction box above the ceiling at the smoke barrier wall in the Emergency Department hallway. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:23pm, by observation and interview of the Maintenance Supervisor the facility failed to properly cover an open electrical junction box above the ceiling at the smoke barrier wall at X-Ray. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:33pm, by observation and interview of the Maintenance Supervisor the facility failed to properly cover open electrical wires in the ceiling at the smoke barrier wall at Surgery. This finding was verified with the Maintenance Supervisor 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 X-Ray Reading Room, Med Room at room #114, Tub Room at room #114, OR/Scope Area and janitor closet in the Surgery Corridor 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 5/8/13 at approximately 12:00pm, by observation and interview of the Maintenance Supervisor the door on the X-Ray Reading Room failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:13pm, by observation and interview of the Maintenance Supervisor the door on the Med Room at room #114 failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:14pm, by observation and interview of the Maintenance Supervisor the door on the Tub Room at room #114 failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:30pm, by observation and interview of the Maintenance Supervisor the door on the OR/Scope Area failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:33pm, by observation and interview of the Maintenance Supervisor the door on the janitor closet in the Surgery Corridor failed to properly close and latch when tested. This finding was verified with the Maintenance Supervisor 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 wall in the Old Incinerator Room, basement at the linen room, elevator control room in the basement, southend of the Tunnel, smoke barrier wall in the Emergency Department Hallway and the smoke barrier wall at room #109 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 5/8/13 at approximately 11:20am, by observation and interview of the Maintenance Supervisor penetrations in the Old Incinerator Room failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 11:26am, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall in the basement at the linen room failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 11:31am, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall in the elevator control room in the basement failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 11:35am, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall at the south end of the tunnel failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:05pm, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall in the Emergency Department Hallway failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:11pm, by observation and interview of the Maintenance Supervisor penetrations of the smoke barrier wall at room #109 failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, the facility failed to provide documentation that the automatic sprinkler system for the facility is maintained and/or tested in accordance with the LSC, section 19.7.6, 4.6.12, 9.7.5. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 5/8/13 at approximately 10:47am, during record review and interview of the Maintenance Supervisor the facility failed to provide documentation of the required annual test of the facilities sprinkler system. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that the facilities cooking facilities were inspected and documented in accordance with the LSC, section 19.3.2.6. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/8/13 at approximately 10:47am, during record review and interview of the Maintenance Supervisor the facility failed to provide documentation of the required semi-annual testing of the facilities cooking equipment. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure the generator was exercised under load for the months of March and April of 2013 and performance of a FULL LOAD BANK test in accordance with NFPA 99, section 3.4.4.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 5/8/13 at approximately 10:33am, during record review and interview of the Maintenance Supervisor the facility failed to properly document the required monthly 30-minute load test of the facilities generator. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 10:34am, during record review and interview of the Maintenance Supervisor the facility failed to provide documentation of the required FULL LOAD BANK test for the facilities generator. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure electrical wiring to be in accordance with NFPA 70, National Electrical Code, section 9.1.2 by having open electrical wires in the mechanical room in the basement, open electrical junction box above the ceiling at the smoke barrier wall in the Emergency Department hallway, open electrical junction box above the ceiling at the smoke barrier wall at X-Ray and having open wiring in the ceiling at the smoke barrier wall to Surgery. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/8/13 at approximately 11:22am, by observation and interview of the Maintenance Supervisor the facility failed to properly cover open electrical wires in the mechanical room in the basement. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:05pm, by observation and interview of the Maintenance Supervisor the facility failed to properly cover an open electrical junction box above the ceiling at the smoke barrier wall in the Emergency Department hallway. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:23pm, by observation and interview of the Maintenance Supervisor the facility failed to properly cover an open electrical junction box above the ceiling at the smoke barrier wall at X-Ray. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 5/8/13 at approximately 12:33pm, by observation and interview of the Maintenance Supervisor the facility failed to properly cover open electrical wires in the ceiling at the smoke barrier wall at Surgery. This finding was verified with the Maintenance Supervisor at the time of discovery.