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Based on observation and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility by increasing the amount of flame and smoke spread during a fire emergency.

Findings include:

1. On 8/18/10 at approximately 9:00 AM during review of records, the facility failed to provide flame spread documentation for wall coverings used in the newly remodeled patient areas. This observation was verified by the Maintenance Director.







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Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. . This deficient practice could potentially affect 50% of the occupants of the facility by allowing heat and fire gases to pass from the affected room into the exit corridor during a fire.

Findings include:

1. On 8/18/10 at approximately 10:40 AM the door to the men's television lounge was observed to be held in the open position with a rubber wedge. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 10:45 AM the door to the women's television lounge was observed to be held in the open position with a rubber wedge. This observation was verified by the Maintenance Director.





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Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1. This deficient practice could potentially affect 20% of the occupants of the facility by allowing heat and smoke to pass between floors during a fire.

Findings include:

1. On 8/18/10 at approximately 11:40 AM the door to the second floor circular stairway did not self close and positively latch. This observation was verified by the Maintenance Director.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility by allowing heat and fire gases to escape from the hazardous areas and enter the exit corridor system during a fire.

Findings include:

1. On 8/18/10 at approximately 10:30 AM the door to the LL-Mechanical-1 room did not self close and positively latch. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 11:00 AM the door to electrical room 3 did not self close and positively latch. This observation was verified by the Maintenance Director.

3. On 8/18/10 at approximately 11:40 AM the E & T 1 electrical/mechanical room was observed to have multiple unprotected penetrations of wires and conduit in the corridor wall. This observation was verified by the Maintenance Director.





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Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1.
This deficient practice could potentially affect all occupants of the facility in the event the emergency battery operated lighs failed to operate as required during an electrical power outage.

Findings include:

1. On 8/18/10 at approximately 9:30 AM during review of records, the facility failed to present consistant records of 30 second monthly and 90 minute annual testing of the facility's battery powered emergency lights. This observation was verified by the Maintenance Director.








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Based on observation and/or review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

1. On 8/18/10 at approximately 9:45 AM during review of records, it was observed that the facility fire plan does not include all code requirements of section 19.7.2.2. The facility plan states that upon location of fire, staff shall remove residents from the affected area to the front parking lot. There is no direction for removal/evacuation to the adjacent smoke compartment. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 9:50 AM during review of records it was observed that facility's fire emergency plan did not address a code phrase for reporting a fire to other staff members. The policy is referred to as the "code red" policy in the index of the facility's procedure book. This observation was verified by the Maintenance Director.






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Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

1. On 8/18/10 at approximately 8:30 AM during review of records, it was observed that the facility failed to conduct fire drills at varied times on the second and third shifts during the past four quarters. Second shift drills are consistently held at approximately 3:30 PM. Third shift drills are consistently held at approximately 6:30 AM. This observation was verified by the Maintenance Director.







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Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility in the event the fire alarm system failed to operate as designed and did not alert the occupants to the presence of a fire in the facility.

Findings include:

1. On 8/18/10 at approximately 9:15 AM during review of records it was observed that the documentation for the annual inspection was not complete. The documentation did not include the inspection company's address or phone number, technician's name, or any information on the FACP and battery status. This observation was verified by the Maintenance Director.








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Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all occupants of the facility in the event the smoke detection sytem failed to operate as designed and did not activate the facility's fire alarm system.

Findings include:

1. On 8/18/10 at approximately 9:20 AM during review of records the facility failed to present documentation of smoke detector sensitivity testing. This observation was verified by the Maintenance Director.







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Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect 10% of the occupants of the facility if a fire started in an unprotected area of the facility.

Findings include:

1. On 8/18/10 at approximately 10:55 AM it was observed that the small storage room near the ambulance entrance did not contain a sprinkler head. This observation was verified by the Maintenance Director.








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Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1. This deficient practice could potentially affect all occupants of the facility in the event the water supply to the sprinkler system was shut off without staff notification.

Findings include:

1. On 8/18/10 at approximately 10:00 AM it was observed that the first OS & Y valve in line from the water storage tank was not electronically supervised. This observation was verified by the Maintenance Director.






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Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility in the event the sprinkler system failed to operate as designed.

Findings include:

1. On 8/18/10 at approximately 8:45 AM during review of records the facility failed to provide documentation of a 4th quarter 2009 flow test of the automatic sprinkler system. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 11:15 AM the electrical room 2 was observed to be missing a ceiling tile. This observation was verified by the Maintenance Director.




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Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect 10 occupants of the facility if a fire ignited in the kitchen area and the hood system failed to operate, or the staff failed to respond correctly.

Findings include:

1. On 8/18/10 at approximately 8:50 AM during review of records the facility failed to document two concurrent semi-annual testing and maintenance reports for the kitchen hood suppression system. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 10:50 AM it was observed that the kitchen portable "K" fire extinguishers did not have the required instructional placards attached near the extinguishers. This observation was verified by the Maintenance Director.





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Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are in accordance with provisions of 10.3.1 and NFPA 13, Standards for the Installation of Sprinkler Systems. Newly introduced upholstered furniture within health care occupancies meets the criteria specified when tested in accordance with the methods cited in 10.3.2 (2) and 10.3.3. 19.7.5.1, NFPA 13

Newly introduced mattresses meet the criteria specified when tested in accordance with the method cited in 10.3.2 (3) , 10.3.4. 19.7.5.3

Findings include:

1. On 8/18/10 at approximately 9:50 AM during review of records the facility failed to present flame spread documentation for the window treatments used throughout the facility. This observation was verified by the Maintenance Director.





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Based on observation and/or review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility if the emergency generator failed to provide electrical power during an outage.

Findings include:

1. On 8/18/10 at approximately 8:40 AM during review of records the facility failed to present documentation of monthly 30% load calculations. This observation was verified by the Maintenance Director.







.

Based on observation and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility by increasing the amount of flame and smoke spread during a fire emergency.

Findings include:

1. On 8/18/10 at approximately 9:00 AM during review of records, the facility failed to provide flame spread documentation for wall coverings used in the newly remodeled patient areas. This observation was verified by the Maintenance Director.







.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. . This deficient practice could potentially affect 50% of the occupants of the facility by allowing heat and fire gases to pass from the affected room into the exit corridor during a fire.

Findings include:

1. On 8/18/10 at approximately 10:40 AM the door to the men's television lounge was observed to be held in the open position with a rubber wedge. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 10:45 AM the door to the women's television lounge was observed to be held in the open position with a rubber wedge. This observation was verified by the Maintenance Director.





.

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1. This deficient practice could potentially affect 20% of the occupants of the facility by allowing heat and smoke to pass between floors during a fire.

Findings include:

1. On 8/18/10 at approximately 11:40 AM the door to the second floor circular stairway did not self close and positively latch. This observation was verified by the Maintenance Director.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility by allowing heat and fire gases to escape from the hazardous areas and enter the exit corridor system during a fire.

Findings include:

1. On 8/18/10 at approximately 10:30 AM the door to the LL-Mechanical-1 room did not self close and positively latch. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 11:00 AM the door to electrical room 3 did not self close and positively latch. This observation was verified by the Maintenance Director.

3. On 8/18/10 at approximately 11:40 AM the E & T 1 electrical/mechanical room was observed to have multiple unprotected penetrations of wires and conduit in the corridor wall. This observation was verified by the Maintenance Director.





.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1.
This deficient practice could potentially affect all occupants of the facility in the event the emergency battery operated lighs failed to operate as required during an electrical power outage.

Findings include:

1. On 8/18/10 at approximately 9:30 AM during review of records, the facility failed to present consistant records of 30 second monthly and 90 minute annual testing of the facility's battery powered emergency lights. This observation was verified by the Maintenance Director.








.

Based on observation and/or review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

1. On 8/18/10 at approximately 9:45 AM during review of records, it was observed that the facility fire plan does not include all code requirements of section 19.7.2.2. The facility plan states that upon location of fire, staff shall remove residents from the affected area to the front parking lot. There is no direction for removal/evacuation to the adjacent smoke compartment. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 9:50 AM during review of records it was observed that facility's fire emergency plan did not address a code phrase for reporting a fire to other staff members. The policy is referred to as the "code red" policy in the index of the facility's procedure book. This observation was verified by the Maintenance Director.






.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

1. On 8/18/10 at approximately 8:30 AM during review of records, it was observed that the facility failed to conduct fire drills at varied times on the second and third shifts during the past four quarters. Second shift drills are consistently held at approximately 3:30 PM. Third shift drills are consistently held at approximately 6:30 AM. This observation was verified by the Maintenance Director.







.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility in the event the fire alarm system failed to operate as designed and did not alert the occupants to the presence of a fire in the facility.

Findings include:

1. On 8/18/10 at approximately 9:15 AM during review of records it was observed that the documentation for the annual inspection was not complete. The documentation did not include the inspection company's address or phone number, technician's name, or any information on the FACP and battery status. This observation was verified by the Maintenance Director.








.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all occupants of the facility in the event the smoke detection sytem failed to operate as designed and did not activate the facility's fire alarm system.

Findings include:

1. On 8/18/10 at approximately 9:20 AM during review of records the facility failed to present documentation of smoke detector sensitivity testing. This observation was verified by the Maintenance Director.







.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect 10% of the occupants of the facility if a fire started in an unprotected area of the facility.

Findings include:

1. On 8/18/10 at approximately 10:55 AM it was observed that the small storage room near the ambulance entrance did not contain a sprinkler head. This observation was verified by the Maintenance Director.








.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1. This deficient practice could potentially affect all occupants of the facility in the event the water supply to the sprinkler system was shut off without staff notification.

Findings include:

1. On 8/18/10 at approximately 10:00 AM it was observed that the first OS & Y valve in line from the water storage tank was not electronically supervised. This observation was verified by the Maintenance Director.






.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility in the event the sprinkler system failed to operate as designed.

Findings include:

1. On 8/18/10 at approximately 8:45 AM during review of records the facility failed to provide documentation of a 4th quarter 2009 flow test of the automatic sprinkler system. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 11:15 AM the electrical room 2 was observed to be missing a ceiling tile. This observation was verified by the Maintenance Director.




.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect 10 occupants of the facility if a fire ignited in the kitchen area and the hood system failed to operate, or the staff failed to respond correctly.

Findings include:

1. On 8/18/10 at approximately 8:50 AM during review of records the facility failed to document two concurrent semi-annual testing and maintenance reports for the kitchen hood suppression system. This observation was verified by the Maintenance Director.

2. On 8/18/10 at approximately 10:50 AM it was observed that the kitchen portable "K" fire extinguishers did not have the required instructional placards attached near the extinguishers. This observation was verified by the Maintenance Director.





.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are in accordance with provisions of 10.3.1 and NFPA 13, Standards for the Installation of Sprinkler Systems. Newly introduced upholstered furniture within health care occupancies meets the criteria specified when tested in accordance with the methods cited in 10.3.2 (2) and 10.3.3. 19.7.5.1, NFPA 13

Newly introduced mattresses meet the criteria specified when tested in accordance with the method cited in 10.3.2 (3) , 10.3.4. 19.7.5.3

Findings include:

1. On 8/18/10 at approximately 9:50 AM during review of records the facility failed to present flame spread documentation for the window treatments used throughout the facility. This observation was verified by the Maintenance Director.





.

Based on observation and/or review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility if the emergency generator failed to provide electrical power during an outage.

Findings include:

1. On 8/18/10 at approximately 8:40 AM during review of records the facility failed to present documentation of monthly 30% load calculations. This observation was verified by the Maintenance Director.







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