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Based on observation and staff interviews, the door on one of five hazardous areas (two of three kitchen doors) were not maintained to automatically close tightly into the frame affecting approximately 25 patients and approximately 50 staff in the event of fire and smoke inside the building.

Findings include:

1. During the Life Safety Code Survey conducted on July 15, 2014 while touring the interior of the facility from 12:00 p.m. to 4:30 p.m. accompanied by the Engineering Manager revealed on the 1st Level Kitchen/Dishwasher Room-the door between kitchen and dining room would not close properly. The automatic door closer was removed leaving a gap of 1 to 2 inch between door and the door's frame. Observation of the kitchen corridor doors, the corridor double door was being blocked open by a large food cart placed there by a facility's staff member. The facility's staff member left the food cart in the door's pathway and unattended for several minutes. The door would be considered blocked in the open position with an automatic door closer and will defeat the automatic closing function in the event of smoke or fire.

2. During an interview of the Engineering Manager on July 15, 2014 at approximately 3:30 p.m. it was discussed about the facility's issues of the door between the kitchen and dining room and the dryer and washer rooms with automatic door closers on the doors. The Engineering Manager confirmed he observed and understood the deficiencies of not performing the safety functions of the doors.

Based on observation, record review and staff interview, the facility failed to install, test and or maintain (2 of 2 off site buildings) fire alarm system as required affecting approximately 3 patients and approximately 5 staff members at the time of survey.

Findings include:

1. During the Life Safety Code Survey conducted on July 15, 2014 while touring the interior of the facility from 10:40 a.m. to 12:00 p.m. accompanied by the Engineering Manager revealed at the facility's two off site buildings (rehabilitation center and the women's care/sleep center) had no fire alarm system in the facility that treat or care for patients on a daily bases.

2. During the record review conducted on July 15, 2014 from 8:50 a.m. to 10:40 a.m. revealed no documentation of installing, testing, and or maintaining the 2 of 2 off site buildings fire alarm systems. Review of the Survey and Certification Letter 14-28-OPT from the Federal Life Safety states the rehabilitation agencies for Fire Safety Requirements are to have an automatic extinguishing equipment system or an enclosure with 1-hour resistance rating in hazardous areas as well as fire extinguishers, fire alarm systems and a fire evacuation plan.

3. During the interview of the Engineering Manager on July 15, 2014 at approximately 9:40 a.m. it was discussed about the facility's issues with not having a fire alarm system in the facilities that treat or care for patients The Engineering Manager confirmed he observed and understood the deficiencies of the required fire alarm systems to protect the health and safety of patients, personnel, and the public.

4. Observation of the two off site facilities did provide several fire extinguishers and battery operated smoke detectors in each facility. However, the two off site building that care for or treat a patient are required to have a fire alarm system in place.

Based on observation and staff interview, the facility failed to prohibit the use of portable space heating devices that do not exceed 212 degrees F. (100 degrees C) as required in NFPA 101, affecting approximately 25 patients and approximately 50 staff in the event of fire inside the building.

Findings include:

1. During the Life Safety Code Survey conducted on July 15, 2014 while touring the interior of the facility from 12:00 p.m. to 4:30 p.m. accompanied by the Engineering Manager revealed a space heating device that could exceed 212 degrees in the rooms labeled:
1st Level Doctor's Lounge/Sleep Quarters-portable space heater was in use at the time of survey. The portable space heater was discovered on top of a night stand near to the doctor's bed and
1st Level Administration Office-portable space heater was discovered underneath a desk.

2. During an interview of the Engineering Manager on July 15, 2014 at approximately 1:30 p.m. it was discussed about the facility's issues with the removal of the portable space heater devices inside the facility. The Engineering Manager confirmed he observed and understood the deficiencies of the removal and the facility failure to prohibit the use of the portable space heater devices inside the facility building.

Based on observation, record review and staff interview it was determined the facility failed to maintain electrical safety requirements affecting approximately 24 patients and approximately 50 staff in the event of fire inside the building.

Findings include:

1. During the Life Safety Code Survey conducted on July 15, 2014 while touring the interior of the main building from 12:00 p.m. to 4:30 p.m. accompanied by the Engineering Manager revealed flexible cords, (extension cords, power taps, power strips, surge protectors and surge/UPS, uninterruptible power supply), battery back-up units being used as a substitute for the fixed wiring of the facility that is prohibited by NFPA 70. The observations (sampling) were made in the following locations:
2nd Level Rehab Services Room-(In a Patient Care Area) a power strip less than six feet away from a patient and
1st Level Admission Office-power strip with refrigerator.

2. During the Life Safety Code Survey conducted on July 15, 2014 while touring the interior of the rehabilitation center off site building from 10:40 a.m. to 12:00 p.m. accompanied by the Engineering Manager revealed flexible cords, (extension cords, power taps, power strips, surge protectors and surge/UPS, uninterruptible power supply), battery back-up units being used as a substitute for the fixed wiring of the facility that is prohibited by NFPA 70. The observations (sampling) were made in the following locations:
In a Patient Care Area-had five power strips less than six feet away from a patient. 3 of the power strips were removed at the time of survey.

3. During an interview of the Engineering Manager on July 15, 2014 at approximately 2:00 p.m. it was discussed about the facility's issues with the removal of the power strips devices inside the patient care areas and the correct uses of power strips devices. The Engineering Manager confirmed he observed and understood the deficiencies of the removal of the power strip devices that were inside the rooms less than 6 feet away from the patient's personal space and the correct uses of power strip devices.

4. During the record review conducted on July 15, 2014 from 8:50 a.m. to 10:40 a.m. revealed the facility failed to provide documentation of the Essential Electrical System requirements for the annual main & feeder circuit breakers electrical testing and exercise in the past 12 months. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. Power failures are generally associated with failures on the electric utility system. However, many power failures, especially in large facilities, are known to occur within the health care facility. A significant number of these internal power failures occur because of circuit breaker failure. Therefore, circuit breakers should be inspected regularly and tested periodically.

5. During an interview of the Engineering Manager on July 15, 2014 at approximately 9:50 a.m. it was discussed about the facility's issues of performing an annual Essential Electrical System's main and feeder circuit breakers testing on a regularly and periodically bases. He confirmed he observed and understood the deficiencies of not performing Essential Electrical System requirements.

6. During the Life Safety Code Survey conducted on July 15, 2014 while touring the exterior and interior of the facility from 12:00 p.m. to 4:30 p.m. accompanied by the Engineering Manager revealed in the Main Electrical Room no documentation such as a stamp, sticker, or paperwork of the Annual Essential Electrical System's main and feeder circuit breaker testing on the electrical panels or other equipment.