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Based on observation and interview, the facility failed to maintain a set of smoke barrier doors per the requirements of:

2012 NFPA 101, 19.3.7.8, and 8.5.4.1

This deficiency could affect 9 residents.

Findings include:

On 5/22/2018, during a tour of the facility from 8:45 am to 11:45 am, the surveyor observed the smoke barrier doors near the Coordinator's Office had a 1/2" gap between the doors due to the torn seal.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to provide documentation of testing the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.2.1, 8.3.8, 8.4.1, 8.4.2, and 8.4.2.3

Findings include:

On 05/22/2018, during a tour of the facility from 8:45 am to 11:45 am, based on review of documentation and interview the facility failed :

1. To test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature or under operating temperature conditions at not less than 30% of the nameplate kW rating or provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

2. To have a fuel quality test performed at least annually using tests approved by ASTM standards.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to ensure continuing education on the handling and risks associated with oxygen cylinders and other medical gases stored in cylinders per the requirements of:

2012 NFPA 99, 11.5.2.1

This deficiency could affect all residents.

Findings include:

On 5/22/2018, during the review of documentation from 8:45 am to 11:45 am, the facility failed to provide documentation on the following:
1. The qualifications and training of the facility's training personnel on handling oxygen cylinders.
2. Continuing education for their personnel that handle oxygen cylinders
3. Training personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases on the risks associated with their handling and use.
4. A continuing education program for staff that handle oxygen cylinders to include periodic review of safety guidelines and usage requirements for medical gases and their cylinders.

A member of the maintenance staff was present when this deficiency was identified.