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Based on observations and interviews it was determined that the facility failed to maintain integrity of smoke separations. This resulted in the potential for smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. During a tour of the facility on September 21, 2011 from 11:57 a.m. to 2:10 p.m., unsealed penetrations were found throughout the Attic, the ceiling of the Oxygen Storage area, in Triage, in the ceiling of the Housekeeping Closet by X-Ray, in the Administration Closet, in the Lobby, in the Housekeeping Closet by the South Exit, in the Kitchen Wall, above the fire alarm control panel at the Nurse's Station, in the Housekeeping Closet by the DNS Office, at the Cross Corridor Doors by Room 210, in the ceiling and walls of the Records Storage Room in the Basement below CT, in the ceiling of the fire alarm control room and in the wall outside of the Home Health Office.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, 19.3.6.3, 4.6.12.1). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 11:24 a.m., the facility did not have access to NFPA 80 (1999) for the maintenance of fire and smoke doors and windows.

2. On September 21, 2011 at 1:13 p.m., the stairwell door next to the Kitchen was not rated for a two-hour enclosure.

3. On September 21, 2011 at 1:45 p.m., a vent was installed in the corridor door of the Information Systems Room.

4. On September 21, 2011 at 1:48 p.m., the corridor door was obstructed by a door prop in the Home Health Office.

5. On September 21, 2011 at 2:10 p.m., a roller latch was found on the corridor door serving the Hospice Training Room.

Based on observations, interviews and record review it was determined that the facility failed to properly identify exits. This resulted in the potential for panic and confusion during an evacuation (LSC 19.7.1.1) Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 12:58 p.m., the door leading from the Exit Stairwell next to Long Term Care to the Home Health Offices was not marked as "Not An Exit" on the stairwell side. This condition also existed on the Stairwell Door next to the Kitchen, leading to the Basement.

Based on observations and interview it was determined that the facility failed to provide opening protection, which separates exit corridors from hazardous areas with a sprinkler and smoke partition in existing facilities (Ch. 19). This resulted in the potential for the spread of fire/smoke into other portions of the facility including the means of egress during a hostile fire event (LSC 19.3.2.6, 8.2.3.2, 7.2.1.8, 19.3.2.1). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 12:24 p.m., the fire door in X-Ray did not close and latch properly.

2. On September 21, 2011 at 12:52 p.m., there was no closure on the Housekeeping doors near Room 211 and near the South Exit, and the catches were stuffed with a paper towel, preventing the doors from latching.

3. On September 21, 2011 at 1:07 p.m., there was no door closure on the Hopper Room door.

4. On September 21, 2011 at 1:08 p.m., the Kitchen Doors to the corridor were not fire or smoke rated.

5. On September 21, 2011 at 1:20 p.m., the Utility Room door near the DNS Office did not close properly.

Based on observations, record review and interviews it was determined that the facility failed to install corridors in a new (Ch. 18) facility with an 8' clear and unobstructed width . This resulted in the potential for panic and injury to patients & staff during emergency evacuations and relocation (LSC 18.2.3.3, .4). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 1:04 p.m., the Long Term Care corridor measured less than 8-feet in width at the structural columns.

2. On September 21, 2011 at 1:06 p.m., the corridor by the Nurse's Station by the South Exit and the South exit measured less than 8-feet in width from the counter to the wall.

Based on observations and interview it was determined that the facility failed to provide adequate exit illumination to the public way with bulbs arranged so that if one bulb burned out there would still be adequate exit lighting. This resulted in the potential for confusion and panic by patients & staff during emergency evacuation conditions (LSC 19.2.8). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 1:05 p.m., the South Exit Egress was missing a two-bulb light fixture.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 1:18 p.m., there was no disaster manual at the Nurse's Station by the Hopper Room. When a Nurse was asked where the book was located, she was not able to answer.

2. On September 21, 2011 at 1:52 p.m., a review of the facility's disaster manual revealed the following deficiencies: The emergency disaster manual was past due for an annual review (last dated 2/2010), there was no hazard/risk assessment included in the plan, there were no long term transfer agreements with an equivalent facility, the phone list was dated 2/2010, the after-hours contact list was dated 2009, the fire procedure did not include "code red" for alerting staff to a fire, the fire procedure did not include a defend in place strategy, there was no procedure for a bomb threat, there was no staffing policy, there was not a map of the facility that included the utility shut-off locations, there were no directions for manually starting the emergency generator if it did not start automatically, there was no plan for extreme hot or cold weather, there was no plan for a volcano eruption, earthquake, or flooding.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 11:26 a.m., the fire drill forms were found to be incomplete in detail.

Based on observations, record review and interviews it was determined that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.6). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 12:23 p.m., fire alarm notification devices (horn/strobe) were found in the bathrooms of patient rooms 211 and 212. Per interview with the Maintenance Director, it was indicated that this condition existed throughout the patient rooms in the remodeled wing.

2. On September 21, 2011 at 1:17 p.m., the fire alarm pull station next to the Hopper Room was mounted more than 54-inches from the floor and over 42" to 48" above the floor to the handle..

Based on observations, record review and interviews it was determined that the facility failed to test and maintain fire alarm in accordance with NFPA 72. This condition created a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient which constitutes Immediate Jeopardy. Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 3:10 p.m., there was no documentation or evidence that the fire alarm system had been tested, inspected or maintained in accordance with NFPA 72 Standard by a qualified technician. There was no documentation on-site that the system had ever been inspected. A new alarm system was installed in 2008 and there was no documentation of an acceptance test by an AHJ or permit approval. Per interview with the Maintenance Director, who spoke to the company who installed the system, no annual maintenance had been done on the system, but the company had been out to repair an issue in June of 2011.

2. On September 21, 2011 at 11:24 a.m., the facility did not have access to NFPA 72 (1999), the standard for the installation and maintenance of fire alarm systems. There was also no documentation that the maintenance staff had been trained to perform weekly, monthly or quarterly testing of the fire alarm system.

Based on observations and interview it was determined that the facility failed to ensure that there was complete sprinkler coverage in accordance with NFPA 13 for all portions of the building. This resulted in the potential for sprinkler failure and for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 12:17 p.m., the Generator Room, the Carport housing the Emergency Response Vehicle, and the Linen Chute were not protected by fire sprinklers.

2. On September 21, 2011 at 1:25 p.m., there was a shut-off switch connected to the fire sprinkler air compressor. The air compressor and air maintenance device were not UL 2125 compliant for fire sprinklers.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is continuously maintained & in reliable operating condition. This condition created a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient which constitutes Immediate Jeopardy. Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 3:10 p.m., there was no documentation or evidence that the fire sprinkler system had been tested, inspected or maintained in accordance with NFPA 25 Standard by a qualified technician. There was also no documentation of weekly or quarterly tests being performed. Per interview with the Maintenance Director, the fire sprinkler system had not been tested since 2008, when a valve was replaced on the riser.

2. On September 21, 2011 at 11:24 a.m., the facility did not have access to NFPA 25 (1999), the standard for the maintenance of fire sprinkler systems. There was also no documentation that the maintenance staff had been trained to perform weekly, monthly or quarterly testing of the fire sprinkler system.

3. On September 21, 2011 at 12:10 p.m., the fire department connection (FDC) was blocked by a parked car, because the parking space was not striped. And, there was not a red/white sign with six-inch letters indicating the location of the FDC.

4. During the facility tour on September 21, 2011 from 11:57 a.m. to 2:10 p.m., corroded, painted and/or dirty fire sprinkler heads were found in the outside oxygen storage area, Emergency Department exam area, in the X-Ray room and control room, outside the Lab in the corridor, Housekeeping Closet across from X-Ray, in the CT Office, Lobby Entrance, Room 205, Housekeeping Closet by the South Exit, Exit Stairwell near Long Term Care, Dishwashing Area, between the Walk-in Cooler & Freezer, in the Bathroom by the Attic Door, DNS Office, Restroom by the Lobby, Records Storage in the Basement, Laundry Chute Room, Hospice Training Room and the Home Health Breakroom. And, these were not noted on the annual testing by the third party service.

5. On September 21, 2011 at 12:36 p.m., there were loose escutcheon rings found in the CFO's Office.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 11:24 a.m., the facility did not have access to NFPA 10 (1998) for maintaining the fire extinguishers on site.

2. During the facility tour on September 21, 2011 from 11:57 a.m. to 2:10 p.m., the fire extinguisher in the X-Ray Room was past due for service and the fire extinguishers mounted in the Basement were over 60-inches from the floor to the handle.

Based upon record reviews, observations and interviews it was determined that the facility failed to ensure safe smoking practices by residents in the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing patients to a fire and/or smoke environment (LSC 19.7.4). Findings include, but are not limited to:

1. On September 21, 2011 at 12:11 p.m., multiple cigarette butts were found on the ground outside of the Emergency Department and a cigarette receptacle was placed within 10-feet of the door.

Based on observations, record review and interviews it was determined that the facility failed to properly install/maintain building service equipment. This resulted in the potential for a gas leak and unexpected fire (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 11:40 a.m., the annual certification of the building elevator was past due.

2. On September 21, 2011 at 12:06 p.m., there were no seismic straps on the water heaters in the attic or the Laundry Room.

Based on observations and interview it was determined that the facility failed to install an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 12:08 p.m., the exhaust serving the Kitchen Hood was not hinged and did not have flexible electrical wiring per NFPA 96.

2. On September 21, 2011 at 1:10 p.m., there was a deep-fat fryer in the Kitchen that was not protected by a UL 300 suppression system or hood (Type 1).

Based on observations and interview it was determined that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19.7.8). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. During a tour of the facility on September 21, 2011 from 11:57 a.m. to 2:10 p.m., space heaters were found in the Lab, the CT Office, the Isolation Closet by Room 209, and in the Housekeeping Closet by the South Exit.

Based on observations, record review and interviews it was determined that the facility failed to maintain vertical opening enclosures. This resulted in the potential for spreading smoke and/or fire to other floors, exposing residents & staff to a hazardous environment (LSC 19.5.4, 8.4, 9.5, NFPA 82). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 12:43 p.m., the gasket was missing from the 90-minute Laundry Chute Door by the Lobby; there was not a chute-rated door installed in the Basement and the chute was very dirty with lint.

2. On September 21, 2011 at 12:55 p.m., the abandoned incinerator chute door was propped open with a roll of toilet paper in the Housekeeping Closet by the South Exit.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" up to 80" above the floor. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 12:23 p.m., the corridor by the X-Ray Room was reduced below 8-feet in width with a blanket warmer, wheelchair, soda machine and portable x-ray machine.

2. On September 21, 2011 at 12:48 p.m., the corridor by Room 206 was obstructed by linen carts, trash carts and machines for reading vital signs.

3. On September 21, 2011 at 12:52 p.m., the corridor in the Long Term Care area was obstructed by tables and chairs. The exit discharge outside of the South Exit was also blocked by a bench, reducing the path of egress to 33-1/2 inches in width.

4. On September 21, 2011 at 12:56 p.m., storage was found in the exit stairwell by the Long Term Care area.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas (for light switch in oxygen storage room/ref. NFPA 99, A-4-3.1.1.2(a)2 #4). This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19.3.2.4, 4.3.1.1.2). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 12:12 p.m., compressed gas tanks were found in the Oxygen Storage area without two chains to secure them. There was also a light fixture that was not installed correctly.

Based on observations, record review and interview facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include:

1. On September 21, 2011 at 12:46 p.m., the facility did not have documentation of daily humidity readings in the procedure rooms. Per interview with the Maintenance Director, the facility did not obtain these readings as part of their daily maintenance.

Based on observations and interview it was determined that the facility failed to maintain dryers (NFPA 54). This resulted in the potential for unexpected ignition source & excessive fire spread. Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 1:36 p.m., the dryer duct in the Laundry Room was not sealed with listed duct tape.

Based on observations, and interviews it was determined that the facility failed to store flammable & combustible liquids in an approved manner. This resulted in the potential for flammable fumes in uncontrolled areas (LSC 10.7.2.1, NFPA 99, NFPA 45, NFPA 30). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 12:15 p.m., flammable liquids were stored in the Generator Room.

Based on record review and interviews it was determined that the facility failed to have the medical gas system tested and certified annually. This resulted in the potential for injury to the patients (NFPA 99, Ch. 4). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 11:40 p.m., the facility did not have documentation of a current medical gas system certificate.

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. This condition created a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient which constitutes Immediate Jeopardy. Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 3:10 a.m., there was no documentation or evidence that the emergency generator had been tested, inspected or maintained in accordance with NFPA 110 Standard by a qualified technician since it was installed. This included a 4-hour load bank test to be conducted every 3 years.

2. On September 21, 2011 at 11:24 a.m., the facility did not have access to NFPA 110 (1999), the standard for maintaining the emergency generator. The maintenance staff did not have documentation that they were trained to conduct the weekly and monthly maintenance of the emergency generator.

3. On September 21, 2011 at 12:14 p.m., the emergency generator did not have a battery-powered emergency light in the generator room or electrical room where the transfer switch is located, there was no emergency shut off switch outside of the generator room, and the diesel fuel tank did not have a vent to the outside 12-feet above grade. There was also no documentation of a weekly check of the electrolyte levels of the generator batteries.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 11:58 a.m., in the Attic there were extension cords being used as permanent wiring, one of which was serving the HVAC unit. There was also a plug adapter into a light socket, multiple open junction boxes and multiple extension cords that were plugged into a 4-way plug into an adapter with temporary lighting.

2. During a tour of the facility on September 21, 2011 from 11:57 a.m. to 2:10 p.m., relocatable power taps were found in Triage, the Drawing Room, the Lab and Lab Office, in the CT Office, the CFO's Office, in the Administration Office area, the Admitting Office, the aquarium in the Day Room of Long Term Care, in the Kitchen by the sink and the Main Nurse's Station.

3. On September 21, 2011 at 12:22 p.m., a non-GFCI protected wire mould was found within 6-feet of the sink in the Lab.

4. On September 21, 2011 at 12:45 p.m., an outlet cover was missing near the television in Room 204. Per interview, this condition existed throughout the patient rooms.

5. On September 21, 2011 at 12:52 p.m., an extension cord was serving the power cord of the bed in Room 211.

6. On September 21, 2011 at 12:58 p.m., an open junction box was found in the Exit Stairwell by the Long Term Care area.

7. On September 21, 2011 at 1:12 p.m., a household-rated microwave was in the Employee Breakroom.

8. On September 21, 2011 at 1:15 p.m., an Electrical Panel was obstructed by the Attic Door.

9. On September 21, 2011 at 1:50 p.m., in the Home Health Breakroom, an ice maker was plugged into an extension cord, then plugged into a relocatable power tap. There was also a household-rated microwave and toaster.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire sprinkler system shutdown that identified their procedures to follow when the fire sprinkler system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of residents/patients & staff to a safe refuge. Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 2:05 p.m., the facility did not have a procedure for conducting a fire watch or notification to the OSFM if the fire sprinkler system was out of service for more than 4-hours.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire alarm system shutdown that identified their procedures to follow when the fire alarm system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of residents/patients & staff to a safe refuge. Surveyor was accompanied by the Maintenance Supervisor and EMS Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 21, 2011 at 2:05 p.m., the facility did not have a plan for conducting a fire watch or notification of the OSFM if the fire alarm system was out of service for more than 4-hours.