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Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the doors on the vacuum room in the basement and the nourishment room next to room #104 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 7/22/10 at approximately 10:32am, by observation and interview of the Safety Director, the door on the vacuum room in the basement failed to properly close and latch. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 11:33am, by observation and interview of the Safety Director, the door on the door on the nourishment room next to room #104 failed to properly close and latch. 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 in the vacuum room in the basement, fire suppression riser room in the basement, smoke barrier wall at the server room in the basement, elevator control room in the basement, boiler room, IDF closet, smoke barrier wall at the vending machines and the coat closet at the Admitting Office 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 7/22/10 at approximately 10:31am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the vacuum room in the basement failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 10:39am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the fire suppression riser room in the basement failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 10:40am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the server room in the basement failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 10:43am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the elevator control room the basement failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 10:59am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the boiler room failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 11:02am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the IDF closet failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 11:07am, 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 7/22/10 at approximately 11:12am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the coat closet at the Admitting Office failed to be properly sealed. 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 there was a written plan for the protection of all patients and for their evacuation in the event of an emergency that was reviewed by staff annually in accordance with the LSC, section 19.7.1.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 10:22am, during record review and interview of the Safety Director, a written plan for the protection of all patients and for their evacuation in the event of an emergency was not reviewed and/or updated annually. This finding was verified with the Safety Director at the time of discovery.

Based upon record review, observation and staff interview, it was determined that the facility failed to ensure that staff to be familiar with the facilities fire evacuation procedures by failing to conduct fire drills at varying times and staff failed to locate activated smoke detector during fire drill in accordance with the LSC, section 19.7.1.2. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 9:59am, during record review and interview of the Safety Director, the facility failed to conduct fire drills at varying time throughout the calendar year. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 11:28am, by observation and interview of the Safety Director, staff failed to located an activated smoke detector during a fire drill/alarm activation in the facility. 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 fire alarm system for the facility was inspected and tested in accordance with NFPA 72, National Fire Alarm Code by failing to have installation dates on batteries in the fire alarm panel. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 11:43am, by observation and interview of the Safety Director, the facility failed to have installation dates on the batteries in the main fire alarm panel. 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 have a policy addressing when the sprinkler system was out of service for more than four hours in a 24 hour period that included all the information required by the LSC, section 9.7.6.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 10:06am, during record review and interview of the Safety Director, the Fire Watch Policy for the sprinkler system failed to have notification of the State Agency in the policy. 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 have a policy addressing when the fire alarm system was out of service for more than four hours in a 24 hour period that included all the information required by the LSC, section 9.7.6.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 10:06am, during record review and interview of the Safety Director, the Fire Watch Policy for the fire alarm system failed to have notification of the State Agency in the policy. 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 doors on the vacuum room in the basement and the nourishment room next to room #104 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 7/22/10 at approximately 10:32am, by observation and interview of the Safety Director, the door on the vacuum room in the basement failed to properly close and latch. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 11:33am, by observation and interview of the Safety Director, the door on the door on the nourishment room next to room #104 failed to properly close and latch. 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 in the vacuum room in the basement, fire suppression riser room in the basement, smoke barrier wall at the server room in the basement, elevator control room in the basement, boiler room, IDF closet, smoke barrier wall at the vending machines and the coat closet at the Admitting Office 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 7/22/10 at approximately 10:31am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the vacuum room in the basement failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 10:39am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the fire suppression riser room in the basement failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 10:40am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the server room in the basement failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 10:43am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the elevator control room the basement failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 10:59am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the boiler room failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 11:02am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the IDF closet failed to be properly sealed. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 11:07am, 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 7/22/10 at approximately 11:12am, by observation and interview of the Safety Director, penetrations of the smoke barrier wall in the coat closet at the Admitting Office failed to be properly sealed. 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 there was a written plan for the protection of all patients and for their evacuation in the event of an emergency that was reviewed by staff annually in accordance with the LSC, section 19.7.1.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 10:22am, during record review and interview of the Safety Director, a written plan for the protection of all patients and for their evacuation in the event of an emergency was not reviewed and/or updated annually. This finding was verified with the Safety Director at the time of discovery.

Based upon record review, observation and staff interview, it was determined that the facility failed to ensure that staff to be familiar with the facilities fire evacuation procedures by failing to conduct fire drills at varying times and staff failed to locate activated smoke detector during fire drill in accordance with the LSC, section 19.7.1.2. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 9:59am, during record review and interview of the Safety Director, the facility failed to conduct fire drills at varying time throughout the calendar year. This finding was verified with the Safety Director at the time of discovery.

On 7/22/10 at approximately 11:28am, by observation and interview of the Safety Director, staff failed to located an activated smoke detector during a fire drill/alarm activation in the facility. 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 fire alarm system for the facility was inspected and tested in accordance with NFPA 72, National Fire Alarm Code by failing to have installation dates on batteries in the fire alarm panel. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 11:43am, by observation and interview of the Safety Director, the facility failed to have installation dates on the batteries in the main fire alarm panel. 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 have a policy addressing when the sprinkler system was out of service for more than four hours in a 24 hour period that included all the information required by the LSC, section 9.7.6.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 10:06am, during record review and interview of the Safety Director, the Fire Watch Policy for the sprinkler system failed to have notification of the State Agency in the policy. 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 have a policy addressing when the fire alarm system was out of service for more than four hours in a 24 hour period that included all the information required by the LSC, section 9.7.6.1. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 7/22/10 at approximately 10:06am, during record review and interview of the Safety Director, the Fire Watch Policy for the fire alarm system failed to have notification of the State Agency in the policy. This finding was verified with the Safety Director at the time of discovery.