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Based on observation, it was determined the facility failed to maintain all smoke detectors.

The findings included:

Observations during the initial tour on 11/16/11 revealed the following:
a. At 9:10 AM, no smoke detector was located within 5 feet of the double corridor doors near dietary as required for doors with magnetic hold open devices.
b. At 11:15 AM, 1 of 1 smoke detectors in the corridor outside of the conference room was not installed at least 3 feet from the air return as required.
c. At 12:40 PM, the duct detector above the ceiling in the corridor between patient rooms 300 and 302 had a label stating "disconnected" and did not have a light indicating the detector was active.
d. At 12:43 PM, no smoke detector was located within 5 feet of the double corridor doors between resident rooms 300 and 302 as required for doors with magnetic hold open devices.

The finding was acknowledged by the Administrative Assistant and verified by the Maintenance Assistant at the exit interview on 11/16/11.

Based on observation and record review, it was determined the facility failed to maintain and test a complete automatic sprinkler system.

The findings included:

Observations during the initial tour on 11/16/11 at 9:07 AM revealed 3 of 7 sprinkler heads in dietary were corroded and in need of replacement.

Review of the facility's sprinkler testing reports on 11/16/11 at 1:01 PM in the maintenance office revealed the sprinkler system alarm devices were not inspected quarterly as required.

Review of the facility's annual sprinkler testing report dated 10/20/11 on 11/16/11 at 1:05 PM in the maintenance office revealed the following:
a. Two of 2 gauges on the sprinkler riser were over 5 years old and in need of replacement or recalibrating.
b. The sprinkler system did not have a 5 year obstruction investigation conducted within the last 5 years.
c. Two of 2 dry pendant sprinkler heads (1 in the walk in freezer and 1 in the walk in cooler) were over 10 years old and in need of replacement.

The finding was acknowledged by the Administrative Assistant and the Maintenance Assistant at the exit interview on 11/16/11.

Based on observation, it was determined the facility failed to provide metal containers with self-closing cover devices at all smoking areas.

The findings included:

Observations during the initial tour on 11/16/11 beginning at 9:20 AM revealed no metal containers with self-closing cover devices into which ashtrays can be emptied were provided at the following smoking areas:
a. loading dock
b. picnic area
c. emergency room entrance
d. medical surgical 300 hall exit

The finding was acknowledged by the Administrative Assistant and the Maintenance Assistant at the exit interview on 11/16/11.

Based on observation, it was determined the facility failed to maintain all electrical wiring and components.

The findings included:

Observations during the initial tour on 11/16/11 revealed the following:
a. At 10:42 AM, 2 of 2 electrical receptacles in the handicap shower room on the medical surgical hall were not ground fault circuit interrupter (GFCI) type receptacles.
b. At 10:47 AM, 1 of 1 emergency electrical receptacles in operating room #1 had an open ground.
c. At 10:50 AM, 1 of 1 emergency electrical receptacles in operating room #2 had an open ground.
d. At 10:54 AM, 2 of 2 emergency electrical receptacles at the laboratory processing counter had an open ground.
e. At 10:55 AM, 1 of 1 emergency electrical receptacles at the laboratory send out area had an open ground.
f. At 10:58 AM, 1 of 1 emergency electrical receptacles at the laboratory microscope counter had an open ground.
g. At 11:50 AM, the electrical conduit to the wind sock on the roof was broken in 3 places and in need of repair.
h. At 11:59 AM, the electrical conduit to upblast fan #14 was broken and in need of repair.

The finding was acknowledged by the Administrative Assistant and verified by the Maintenance Assistant at the exit interview on 11/16/11.

Based on observation, it was determined the facility failed to maintain all smoke detectors.

The findings included:

Observations during the initial tour on 11/16/11 revealed the following:
a. At 9:10 AM, no smoke detector was located within 5 feet of the double corridor doors near dietary as required for doors with magnetic hold open devices.
b. At 11:15 AM, 1 of 1 smoke detectors in the corridor outside of the conference room was not installed at least 3 feet from the air return as required.
c. At 12:40 PM, the duct detector above the ceiling in the corridor between patient rooms 300 and 302 had a label stating "disconnected" and did not have a light indicating the detector was active.
d. At 12:43 PM, no smoke detector was located within 5 feet of the double corridor doors between resident rooms 300 and 302 as required for doors with magnetic hold open devices.

The finding was acknowledged by the Administrative Assistant and verified by the Maintenance Assistant at the exit interview on 11/16/11.

Based on observation and record review, it was determined the facility failed to maintain and test a complete automatic sprinkler system.

The findings included:

Observations during the initial tour on 11/16/11 at 9:07 AM revealed 3 of 7 sprinkler heads in dietary were corroded and in need of replacement.

Review of the facility's sprinkler testing reports on 11/16/11 at 1:01 PM in the maintenance office revealed the sprinkler system alarm devices were not inspected quarterly as required.

Review of the facility's annual sprinkler testing report dated 10/20/11 on 11/16/11 at 1:05 PM in the maintenance office revealed the following:
a. Two of 2 gauges on the sprinkler riser were over 5 years old and in need of replacement or recalibrating.
b. The sprinkler system did not have a 5 year obstruction investigation conducted within the last 5 years.
c. Two of 2 dry pendant sprinkler heads (1 in the walk in freezer and 1 in the walk in cooler) were over 10 years old and in need of replacement.

The finding was acknowledged by the Administrative Assistant and the Maintenance Assistant at the exit interview on 11/16/11.

Based on observation, it was determined the facility failed to provide metal containers with self-closing cover devices at all smoking areas.

The findings included:

Observations during the initial tour on 11/16/11 beginning at 9:20 AM revealed no metal containers with self-closing cover devices into which ashtrays can be emptied were provided at the following smoking areas:
a. loading dock
b. picnic area
c. emergency room entrance
d. medical surgical 300 hall exit

The finding was acknowledged by the Administrative Assistant and the Maintenance Assistant at the exit interview on 11/16/11.

Based on observation, it was determined the facility failed to maintain all electrical wiring and components.

The findings included:

Observations during the initial tour on 11/16/11 revealed the following:
a. At 10:42 AM, 2 of 2 electrical receptacles in the handicap shower room on the medical surgical hall were not ground fault circuit interrupter (GFCI) type receptacles.
b. At 10:47 AM, 1 of 1 emergency electrical receptacles in operating room #1 had an open ground.
c. At 10:50 AM, 1 of 1 emergency electrical receptacles in operating room #2 had an open ground.
d. At 10:54 AM, 2 of 2 emergency electrical receptacles at the laboratory processing counter had an open ground.
e. At 10:55 AM, 1 of 1 emergency electrical receptacles at the laboratory send out area had an open ground.
f. At 10:58 AM, 1 of 1 emergency electrical receptacles at the laboratory microscope counter had an open ground.
g. At 11:50 AM, the electrical conduit to the wind sock on the roof was broken in 3 places and in need of repair.
h. At 11:59 AM, the electrical conduit to upblast fan #14 was broken and in need of repair.

The finding was acknowledged by the Administrative Assistant and verified by the Maintenance Assistant at the exit interview on 11/16/11.