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Based upon observation and staff interview it was determined that the facility failed to provide appropriate construction standards by failing to replace missing ceiling tiles in the utility closet next to room #116 in accordance with the LSC, section 19.1.6. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/22/12 at approximately 11:11am, by observation and interview of the Safety Director the facility failed to replace a missing ceiling tile in the utility closet next to room #116. This finding was verified with the Safety Director 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 south kitchen door to the corridor in the lower level, the north kitchen door in the lower level and the door to the Maintenance Department in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/22/12 at approximately 11:37am, by observation and interview of the Safety Director the south kitchen door to the corridor in the lower level failed to close and latch properly when tested. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:41am, by observation and interview of the Safety Director the north kitchen door to the corridor in the lower level failed to close and latch properly when tested. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:50am, by observation and interview of the Safety Director the door to the Maintenance Department failed to close, latch and stop the passage of smoke properly when tested. This finding was verified with the Safety Director 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 at room #116, smoke barrier at the vending machines, the MDF closet at Exam Room #1 and the smoke barrier at the Chart Room 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 5/22/12 at approximately 11:16am, by observation and interview of the Safety Director penetrations of the smoke barrier wall at room #116 failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:19am, by observation and interview of the Safety Director penetrations of the smoke barrier wall at the vending machines failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:30am, by observation and interview of the Safety Director penetrations of the smoke barrier wall in the MDF closet at Exam Room #1 failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:32am, by observation and interview of the Safety Director penetrations of the smoke barrier wall at the Chart Room failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that the dry sprinkler system was inspected and tested in accordance with the LSC, section 19.3.5 by failing to have the air compressor monitored by the facilities fire alarm system. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 5/22/12 at approximately 11:53am, by observation and interview of the Safety Director, the air compressor to the dry sprinkler system for the attic to the facility failed to be monitored by the facilities fire alarm system. This finding was verified with the Safety Director at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that the generator was exercised under load monthly by failing to properly document times properly in accordance with NFPA 99, section 3.4.4.1. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/22/12 at approximately 10:35am, during record review and interview of the Safety Director the facility failed to properly document the monthly load testing of the facilities generator. This finding was verified with the Safety Director at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to provide appropriate construction standards by failing to replace missing ceiling tiles in the utility closet next to room #116 in accordance with the LSC, section 19.1.6. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/22/12 at approximately 11:11am, by observation and interview of the Safety Director the facility failed to replace a missing ceiling tile in the utility closet next to room #116. This finding was verified with the Safety Director 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 south kitchen door to the corridor in the lower level, the north kitchen door in the lower level and the door to the Maintenance Department in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/22/12 at approximately 11:37am, by observation and interview of the Safety Director the south kitchen door to the corridor in the lower level failed to close and latch properly when tested. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:41am, by observation and interview of the Safety Director the north kitchen door to the corridor in the lower level failed to close and latch properly when tested. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:50am, by observation and interview of the Safety Director the door to the Maintenance Department failed to close, latch and stop the passage of smoke properly when tested. This finding was verified with the Safety Director 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 at room #116, smoke barrier at the vending machines, the MDF closet at Exam Room #1 and the smoke barrier at the Chart Room 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 5/22/12 at approximately 11:16am, by observation and interview of the Safety Director penetrations of the smoke barrier wall at room #116 failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:19am, by observation and interview of the Safety Director penetrations of the smoke barrier wall at the vending machines failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:30am, by observation and interview of the Safety Director penetrations of the smoke barrier wall in the MDF closet at Exam Room #1 failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 5/22/12 at approximately 11:32am, by observation and interview of the Safety Director penetrations of the smoke barrier wall at the Chart Room failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that the dry sprinkler system was inspected and tested in accordance with the LSC, section 19.3.5 by failing to have the air compressor monitored by the facilities fire alarm system. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 5/22/12 at approximately 11:53am, by observation and interview of the Safety Director, the air compressor to the dry sprinkler system for the attic to the facility failed to be monitored by the facilities fire alarm system. This finding was verified with the Safety Director at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that the generator was exercised under load monthly by failing to properly document times properly in accordance with NFPA 99, section 3.4.4.1. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 5/22/12 at approximately 10:35am, during record review and interview of the Safety Director the facility failed to properly document the monthly load testing of the facilities generator. This finding was verified with the Safety Director at the time of discovery.