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Based on observation, the facility failed to maintain the integrity of the building, by failing to ensure that penetrations in ceilings and/or walls are sealed with fire rated material. This deficient practice can result in the spread of fire and/or smoke to other areas of the facility, affecting 20 of 51 smoke compartments.

Findings:

During a tour of the facility, on 4/19/20, the following deficiencies were observed at the following times and locations:
a) At 10:57 a.m., 3 quarter sized unsealed penetrations were observed in the west all of room 108.
b) At 11:19 a.m., a 1/4 in. unsealed penetrations was observed in the ceiling by the east wall, located inside the dayroom storage closet, unit 2.
c) At 11:20 a.m., a 1 in. penetration was observed in the ceiling by the south wall, located in the electrical panel closet, inside the social service office, unit 3.
d) At 11:44 a.m., a 3 in. unsealed conduit pipe was observed in the ceiling of the access control room, located in the non-patient care corridor.
e) At 12:05 p.m., 22 dime sized unsealed penetrations were observed in the south wall of the PHP medical directors office. Also a 1/2 in. unsealed penetration was observed in the ceiling by the north wall.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing and latching. Corridor doors are required to close and latch. If a corridor door is equipped with a self-closing device the self-closure must close and latch the corridor door. Corridor doors are to resist fire for 20 minutes if the door is not 1 3/4 in. solid bonded core wood. The facility's corridor doors are metal doors approximately 1 in. wide. Failure to maintain corridor doors could result in the rapid spread of fire and/or smoke throughout the facility. This deficient practice affected 9 of 9 smoke compartments.

Findings:


During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 10:56 a.m., the corridor door to unit 1, staff lounge failed to latch when tested.
b) At 10:58 a.m., the corridor door to the shower room by room 108 was observed equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
c) At 11:16 a.m., the corridor door to the unit 2 art room was observed equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
d) At 11:18 a.m., 2 dime sized unsealed penetrations were observed in the door frame to the unit 2 dayroom.
e) At 11:20 a.m., the fire rating label on the corridor door and door frame to room 310 was observed painted.
f) At 11:26 a.m., the fire rating label on the corridor door and door frame to room 403 was observed painted.
g) At 11:26 a.m., the fire rating label on the corridor door and door frame to room 404 was observed painted.
h) At 11:26 a.m., the fire rating label on the corridor door and door frame to room 405 was observed painted.
i) At 11:33 a.m., the fire rating labels on the corridor door and door frame to the social service office #1 and #2 doors was observed painted.
j) At 11:38 a.m., the fire rating labels on the double corridor door and door frame to the unit 3 dayroom were observed painted.
k) At 11:39 a.m., the fire rating label on the corridor door and door frame to room the physicians consult room, unit 3, was observed painted.
l)At 11:40 a.m., the fire rating label on the corridor door and door frame to the punching bag room, unit 3, was observed painted.
m) At 11:40 a.m., the fire rating label on the corridor door and door frame to the back entrance of the children's dayroom was observed painted.
n) At 11:40 a.m., the fire rating label on the corridor door and door frame to the janitor's closet by the back entry to the children's day room was observed painted.
o) At 11:41 a.m., the fire rating label on the corridor door and door frame to the clinical educator's office, non-patient care corridor, was observed painted.
p) At 11:43 a.m., the fire rating label on the corridor door and door frame to the maintenance shop was observed painted.
q) At 11:44 a.m., the fire rating label on the corridor door and door frame to the access control room, non-patient care corridor, was observed painted.
r) At 11:45 a.m., the fire rating label on the corridor door and door frame to the medical records file room #3 was observed painted.
s) At 11:47 a.m., the fire rating label on the corridor door and door frame to the medical records file room #2 was observed painted.
t) At 11:48 a.m., the fire rating label on the double corridor doors and door frame to the medical records room was observed painted.
u) At 12:06 p.m., the corridor door to the PHP staff lounge was removed. The door frame label indicated the door that was originally attached was a fire rated door.
v) At 12:06 p.m., the fire rating label on the corridor door and door frame to the PHP clinical nurse office, was observed painted.
w) At 12:08 p.m., the back entrance door to the DON office, located on the PHP corridor, would not open to full capacity. Items were stored behind the door.
x) At 12:16 p.m., the fire rating label on the corridor door and door frame to the housekeeping closet, located by the medical records office, was observed painted.
y) At 12:16 p.m., 4 dime sized unsealed penetrations were observed in the back of the corridor door to the health information office.
z) At 12:19 p.m., the fire rating label on the corridor door and door frame to the community conference room, was observed painted.
aa) At 12:20 p.m., the admissions office corridor door was obstructed from opening by a vacuum cleaner.
bb) At 12:21 p.m., the admissions intake office door was equipped with a self-closing device. The door was observed wedge between the wall and bathroom door frame, which held the door open.
cc) At 2:30 p.m., the fire rating label on the corridor door and door frame to the unit 3 gym, was observed painted.
dd) At 2:35 p.m., the corridor door to the PHP therapist office had 4 dime sized unsealed penetrations in the door frame. Also a 1/2 in. gap was observed at the top of the door, this door is not smoke tight.
ee) At 2:45 p.m., the corridor door to the HR office was observed propped open by a wooden door wedge.

Based on observation, the facility failed to ensure that smoke barrier walls were intact and would prevent the passage of smoke. Penetrations in the smoke barrier walls, must be sealed with fire rated material to ensure the smoke barrier walls meets the 1/2 hour fire rated requirement. Failure to maintain smoke barrier walls, sealing penetrations with approved fire rated material, could potentially cause fire and/or smoke to spread rapidly through the building without smoke barriers intact. This deficient practice affected 2 of 9 smoke compartments.

Findings:

During a tour of the facility, on 4/19/10, at 9:30 a.m., the smoke barrier wall located by unit 2 day room was observed. The attic space located by the smoke barrier wall was observed littered with broken pieces of sheet rock, several tubes of used fire caulking, used rubber gloves and trash. The litter covered approximately 4 ft. by 4 ft. section of the attic space.

Based on observation, the facility failed to maintain the smoke barrier cross-corridor fire doors. Smoke barrier doors are required to close and latch. A fire rating label provided is to be legible. Failure to maintain cross-corridor fire doors could result in potential harm to 60 of 60 residents affecting 9 of 9 smoke compartments.

Findings:

During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 11:30 a.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by room 401.
b) At 11:35 a.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by room 305.
c) At 12:15 p.m., the cross-corridor fire door located by the PHP staff lounge failed to close and latch.
d) At 12:20 p.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by the unit 3 gym.
e) At 12:25 p.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by the courtyard exit door.
f) At 12:30 p.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by the fire alarm control panel room.
g) At 12:33 p.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by room 301.

Based on observation and staff interview the facility failed to ensure the cross-corridor separation doors used to maintain access control provide a minimum clearance of 81 in. wide. Failure to ensure cross-corridor separation doors open to provide egress through both doors could result in potential harm to all residents and staff members in 3 of 9 smoke compartments.

Findings:During a tour of the facility, on 4/19/10, at 11:10 a.m., the cross-corridor separation doors located by unit 1 leading into the dietary corridor and the cross-corridor separation doors leading from the dietary corridor into unit 2 were observed. The left leaf of both sets of cross-corridor separation doors were observed sealed shut, they did not open. At 11:15 p.m., an interview was conducted with maintenance staff. Maintenance staff stated that the local fire marshal allowed the facility to seal the left leafs of both sets of cross-corridor doors. At 11:20 p.m., maintenance staff was asked to provide documentation from the local jurisdiction approving the cross-corridor doors to be sealed.
On 4/20/10, at 10:40 a.m., staff was asked to provide documentation regarding the cross-corridor separation doors being sealed. Administration staff stated that they were waiting for the facilities architect to provide records. At 5:00 p.m., records were not provided for the approval to seal the cross-corridor separation doors.

Based on observation and document review, the facility failed to maintain and test the battery operated emergency lights located in the generator room, utilization room and community conference room. Failure to ensure the batter operated lights function and are tested routinely in accordance with 7.9, could result in potential harm to all residents and staff members, should the generator fail to function and the battery operated lights fail to function.

NFPA 101, 2000 Edition
7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30
seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration
of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

Findings:

During a tour of the facility, on 4/19/10, battery operated lights were observed in the generator room, the utilization management office and the community conference room.
During document review on 4/20/10, at 4:10 p.m., the facility failed to provide documentation that showed a 30 second monthly test and a 1 1/2 hour annual test was conducted on the 3 battery operated lights.

Based on observation, and record review, the facility failed to maintain battery operated exit signs in accordance with 7.9.1.3., and 7.9. This was evidenced by a lack of documentation for monthly and annual testing of its battery powered emergency exit signs and providing illuminated exit signs above exit doors.. This finding affected 3 of 9 smoke compartments. Failure to maintain and test emergency exit signs could potentially result in delayed evacuation and/or injury in the event of an emergency.


As evidence by:
NFPA 101, 2000 Edition:
7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code?.
7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30
seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration
of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed
at 30-day intervals.


Findings:

1. During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 11:06 a.m., the exit sign provided above the exit door located inside the kitchen was observed. The sign was a red and white paper sign and was not illuminated.
b) At 11:30 a.m., the exit sign provided above the exit door located inside the cafeteria leading to the east hallway was observed. The sign was a red and white paper sign and was not illuminated.

2. During record review, on 4/20/10, at 4:00 p.m., the facility failed to provide documentation for the monthly 30 second test and the 1 1/2 hour annual testing of the 2 batter powered exit signs located in the PHP unit.

Based on document review and staff interview, the facility failed to conduct disaster drills twice per year, ensuring all staff members are in-serviced and/or participate and sign in, as evidence by 11-5.3.9. Failure to conduct semi-annual disaster drills and provide training to all staff members to ensure staff members have knowledge of what to do if a disaster should occur could result in potential harm and/or the death to all residents and/or all staff members.


As evidence by:
NFPA 99, 1999 Edition:
11-5.3.9* Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.


Findings:


During record review, on 4/20/10, at 12:35 p.m., disaster drill records were reviewed. The following deficiencies were observed:
a) The facility failed to conduct semi-annual disaster drills. The facility conducted simulated disaster drills on 6/6/09 and 9/28/09, and on 10/26/09 a power outage occurred and was documented.
b) The facility failed to provide sign in sheet for all staff members who participated in the disaster drills. All staff members are to be in-serviced and participate semi-annual in a disaster drill and the facility must provide documentation of such training.

Based on record review, the facility failed to conduct and/or document simulated fire drills one per quarter, per shift. 12 of 12 fire drill records provided did not have sign in sheets for all staff on duty during the fire drill. The fire drill record forms provided were not completed. Failure to conduct fire drills one per quarter, per shift and ensure fire drill forms are filled out and staff participation is accounted for could result in potential harm to 61 of 61 residents and all staff members should a staff member be untrained in their roles and responsibilities during a fire.

Findings:

During record review, and staff interview, on 4/20/10, at 10:30 a.m., the fire drill records were reviewed. The following deficiencies were observed:
a) Fire drill records were reviewed. 12 of 12 fire drill records did not have all staff on duty, including non patient care staff members who respond to the fire drill location, signed in on the fire drill sign in sheet.
b) Documentation for the a.m., shift fire drill conducted on 4/30/09 was reviewed, the PHP unit "Fire Drill/Emergency exercise observation form", was not filled out.
c) Documentation for the a.m., shift fire drill conducted on 4/30/09 was reviewed, 1 of 2 competency tests attached to the fire drill report was not filled out by unit 3/4 staff members.
d) Documentation for the n.o.c., shift fire drill conducted on 10/10/09, was reviewed, 1 of 2 competency tests attached to the fire drill report was not completed by unit 3 staff members.
e) Documentation for the a.m., shift fire drill conducted on 10/14/09, was reviewed, 3 of 3 competency tests attached to the fire drill report were not filled out by unit 1 staff members.
f) Documentation for the p.m., shift fire drill conducted on 11/30/09, was reviewed, 2 of 2 competency tests attached to the fire drill report was not filled out by unit 3/4 staff members.
g) Documentation for the n.o.c., shift fire drill conducted on 12/29/09, was reviewed, 2 of 2 competency tests attached to the fire drill report was not filled out by unit 1 staff members.
h) Documentation for the n.o.c., shift fire drill conducted on 12/29/09, was reviewed, 2 of 2 competency tests attached to the fire drill report was not filled out by unit 2 staff members.
i) Documentation for the n.o.c., shift fire drill conducted on 12/29/09, was reviewed, 2 of 2 competency tests attached to the fire drill report was not filled out by unit 3/4 staff members.
j) Documentation for the a.m., shift fire drill conducted on 1/7/10, was reviewed, 1 of 2 competency tests attached to the fire drill report was not filled out by unit 3/4 staff members.
k) Documentation for the p.m., shift fire drill conducted on 2/25/10, was reviewed, unit 1"Fire Drill/Emergency exercise observation form", was not filled out.
l) Documentation for the p.m., shift fire drill conducted on 2/25/10, was reviewed, PHP unit "Fire Drill/Emergency exercise observation form", was not filled out.

Based on observation, the facility failed to maintain the fire alarm system and fire alarm system devices to ensure the system and all devices attached to the fire alarm system function properly. Failure to maintain the fire alarm system and fire alarm system devices could result in potential harm to all residents and staff, if the fire alarm system and/or fire alarm system devices fail to function.

Findings:During a test of the fire alarm system, on 4/20/09, the following deficiencies were observed at the following times and locations:
a) At 9/43 a.m., the fire alarm manual pull station located above the desk, nursing station unit 2 was observed obstructed. A fax machine and binders obstructed the manual pull station.
b) At 10:50 a.m., the fire alarm system was tested. The chime/strobe located by room 106 failed to sound an audible alarm

Based on observation, the facility failed to maintain the sprinkler system and/or sprinkler system escutcheon plates. Sprinkler head escutcheon plates are to be tightly fitted to the ceiling. Failure to maintain the sprinkler system escutcheon could result in a sprinkler system malfunction. Malfunction of the sprinkler system could potentially affect 9 of 9 smoke compartments.

Findings:

During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 10:54 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in the bathroom by the consult room, unit 1.
b) At 11:00 a.m., a 1/4 in. gap was observed around 1 of 4 sprinkler escutcheon plates located in the group locker room.
c) At 11:08 a.m., a 1/2 in. gap was observed around 1of 2 sprinkler escutcheon plates located in the dietary dry food storage room.
d) At 11:14 a.m., a 1/2 in. gap was observed around 3 of 4 sprinkler escutcheon plates located in the corridor outside of the dietary department.
e) At 11:18 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in corridor outside of unit 2 dayroom.
f) At 11:19 a.m., a 1/4 in. gap was observed around the sprinkler escutcheon plate located in the corridor outside of the day room, unit 2.
g) At 11:30 a.m., a 1/4 in. gap was observed around the sprinkler escutcheon plate located in janitor's closet by room 404.
h) at 11:41 a.m., 1/4 in. gap was observed around the sprinkler escutcheon plate located in the corridor outside of the linen storage closet, non-patient corridor.
i) At 2:15 p.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in the janitor's closet by room 109.
j) At 2:20 p.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in the corridor outside of the patient article closet, unit 2.

Based on observation, the facility failed to maintain, and utilize the receptacles and/or building electrical components safely, as evidence by NFPA 70 400-8 and 240-4, and HCFA transmittal notice 22-99. Failure to maintain, test and utilize all receptacles within the building could result in potential harm to 75 of 75 residents.


As evidence by:
NFPA 70, 400-8 1999 edition, Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceiling, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

NFPA 70, article 240-4 1999 edition, Protection of Flexible Cords and Fixture Wires.
Flexible cord, including tinsel cord and extension cords, and fixtures wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixtures wire shall be protected against overcurrent in accordance with its ampacity as specified in table 402-5. Supplementary overcurrent protection, as in section 240-10, shall be permitted to be an acceptable mean cor providing this protection.
(b) Supply cord of listed appliance or portable lamps. Where flexible cord or tinsel cord is approved for and used with specific listed appliance or portable lamp, it shall be permitted to be supplied by a branch circuit of Article 210.
Also, HCFA transmittal notice 22-99, prohibits the use of extension cords without overcurrent protection (surge protectors).


Findings:

During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 10:45 a.m., a computer on wheels (COW) was observed stored in the corridor. The electrical cord for the cow was observed running through the door to a bathroom and plugged into the bathroom outlet, located by unit 1 nursing station.
b) At 11:20 a.m., a microwave and a refrigerator were observed plugged into a surge protector, social service office.
c) At 12:20 p.m., a coffee pot and microwave was observed plugged into a surge protector, admissions office.

Based on observation, the facility failed to maintain the integrity of the building, by failing to ensure that penetrations in ceilings and/or walls are sealed with fire rated material. This deficient practice can result in the spread of fire and/or smoke to other areas of the facility, affecting 20 of 51 smoke compartments.

Findings:

During a tour of the facility, on 4/19/20, the following deficiencies were observed at the following times and locations:
a) At 10:57 a.m., 3 quarter sized unsealed penetrations were observed in the west all of room 108.
b) At 11:19 a.m., a 1/4 in. unsealed penetrations was observed in the ceiling by the east wall, located inside the dayroom storage closet, unit 2.
c) At 11:20 a.m., a 1 in. penetration was observed in the ceiling by the south wall, located in the electrical panel closet, inside the social service office, unit 3.
d) At 11:44 a.m., a 3 in. unsealed conduit pipe was observed in the ceiling of the access control room, located in the non-patient care corridor.
e) At 12:05 p.m., 22 dime sized unsealed penetrations were observed in the south wall of the PHP medical directors office. Also a 1/2 in. unsealed penetration was observed in the ceiling by the north wall.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing and latching. Corridor doors are required to close and latch. If a corridor door is equipped with a self-closing device the self-closure must close and latch the corridor door. Corridor doors are to resist fire for 20 minutes if the door is not 1 3/4 in. solid bonded core wood. The facility's corridor doors are metal doors approximately 1 in. wide. Failure to maintain corridor doors could result in the rapid spread of fire and/or smoke throughout the facility. This deficient practice affected 9 of 9 smoke compartments.

Findings:


During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 10:56 a.m., the corridor door to unit 1, staff lounge failed to latch when tested.
b) At 10:58 a.m., the corridor door to the shower room by room 108 was observed equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
c) At 11:16 a.m., the corridor door to the unit 2 art room was observed equipped with a self-closing device. When tested the self-closure failed to close and latch the door.
d) At 11:18 a.m., 2 dime sized unsealed penetrations were observed in the door frame to the unit 2 dayroom.
e) At 11:20 a.m., the fire rating label on the corridor door and door frame to room 310 was observed painted.
f) At 11:26 a.m., the fire rating label on the corridor door and door frame to room 403 was observed painted.
g) At 11:26 a.m., the fire rating label on the corridor door and door frame to room 404 was observed painted.
h) At 11:26 a.m., the fire rating label on the corridor door and door frame to room 405 was observed painted.
i) At 11:33 a.m., the fire rating labels on the corridor door and door frame to the social service office #1 and #2 doors was observed painted.
j) At 11:38 a.m., the fire rating labels on the double corridor door and door frame to the unit 3 dayroom were observed painted.
k) At 11:39 a.m., the fire rating label on the corridor door and door frame to room the physicians consult room, unit 3, was observed painted.
l)At 11:40 a.m., the fire rating label on the corridor door and door frame to the punching bag room, unit 3, was observed painted.
m) At 11:40 a.m., the fire rating label on the corridor door and door frame to the back entrance of the children's dayroom was observed painted.
n) At 11:40 a.m., the fire rating label on the corridor door and door frame to the janitor's closet by the back entry to the children's day room was observed painted.
o) At 11:41 a.m., the fire rating label on the corridor door and door frame to the clinical educator's office, non-patient care corridor, was observed painted.
p) At 11:43 a.m., the fire rating label on the corridor door and door frame to the maintenance shop was observed painted.
q) At 11:44 a.m., the fire rating label on the corridor door and door frame to the access control room, non-patient care corridor, was observed painted.
r) At 11:45 a.m., the fire rating label on the corridor door and door frame to the medical records file room #3 was observed painted.
s) At 11:47 a.m., the fire rating label on the corridor door and door frame to the medical records file room #2 was observed painted.
t) At 11:48 a.m., the fire rating label on the double corridor doors and door frame to the medical records room was observed painted.
u) At 12:06 p.m., the corridor door to the PHP staff lounge was removed. The door frame label indicated the door that was originally attached was a fire rated door.
v) At 12:06 p.m., the fire rating label on the corridor door and door frame to the PHP clinical nurse office, was observed painted.
w) At 12:08 p.m., the back entrance door to the DON office, located on the PHP corridor, would not open to full capacity. Items were stored behind the door.
x) At 12:16 p.m., the fire rating label on the corridor door and door frame to the housekeeping closet, located by the medical records office, was observed painted.
y) At 12:16 p.m., 4 dime sized unsealed penetrations were observed in the back of the corridor door to the health information office.
z) At 12:19 p.m., the fire rating label on the corridor door and door frame to the community conference room, was observed painted.
aa) At 12:20 p.m., the admissions office corridor door was obstructed from opening by a vacuum cleaner.
bb) At 12:21 p.m., the admissions intake office door was equipped with a self-closing device. The door was observed wedge between the wall and bathroom door frame, which held the door open.
cc) At 2:30 p.m., the fire rating label on the corridor door and door frame to the unit 3 gym, was observed painted.
dd) At 2:35 p.m., the corridor door to the PHP therapist office had 4 dime sized unsealed penetrations in the door frame. Also a 1/2 in. gap was observed at the top of the door, this door is not smoke tight.
ee) At 2:45 p.m., the corridor door to the HR office was observed propped open by a wooden door wedge.

Based on observation, the facility failed to ensure that smoke barrier walls were intact and would prevent the passage of smoke. Penetrations in the smoke barrier walls, must be sealed with fire rated material to ensure the smoke barrier walls meets the 1/2 hour fire rated requirement. Failure to maintain smoke barrier walls, sealing penetrations with approved fire rated material, could potentially cause fire and/or smoke to spread rapidly through the building without smoke barriers intact. This deficient practice affected 2 of 9 smoke compartments.

Findings:

During a tour of the facility, on 4/19/10, at 9:30 a.m., the smoke barrier wall located by unit 2 day room was observed. The attic space located by the smoke barrier wall was observed littered with broken pieces of sheet rock, several tubes of used fire caulking, used rubber gloves and trash. The litter covered approximately 4 ft. by 4 ft. section of the attic space.

Based on observation, the facility failed to maintain the smoke barrier cross-corridor fire doors. Smoke barrier doors are required to close and latch. A fire rating label provided is to be legible. Failure to maintain cross-corridor fire doors could result in potential harm to 60 of 60 residents affecting 9 of 9 smoke compartments.

Findings:

During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 11:30 a.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by room 401.
b) At 11:35 a.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by room 305.
c) At 12:15 p.m., the cross-corridor fire door located by the PHP staff lounge failed to close and latch.
d) At 12:20 p.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by the unit 3 gym.
e) At 12:25 p.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by the courtyard exit door.
f) At 12:30 p.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by the fire alarm control panel room.
g) At 12:33 p.m., the fire rating labels on the cross-corridor fire doors and door frame were observed painted, located by room 301.

Based on observation and staff interview the facility failed to ensure the cross-corridor separation doors used to maintain access control provide a minimum clearance of 81 in. wide. Failure to ensure cross-corridor separation doors open to provide egress through both doors could result in potential harm to all residents and staff members in 3 of 9 smoke compartments.

Findings:During a tour of the facility, on 4/19/10, at 11:10 a.m., the cross-corridor separation doors located by unit 1 leading into the dietary corridor and the cross-corridor separation doors leading from the dietary corridor into unit 2 were observed. The left leaf of both sets of cross-corridor separation doors were observed sealed shut, they did not open. At 11:15 p.m., an interview was conducted with maintenance staff. Maintenance staff stated that the local fire marshal allowed the facility to seal the left leafs of both sets of cross-corridor doors. At 11:20 p.m., maintenance staff was asked to provide documentation from the local jurisdiction approving the cross-corridor doors to be sealed.
On 4/20/10, at 10:40 a.m., staff was asked to provide documentation regarding the cross-corridor separation doors being sealed. Administration staff stated that they were waiting for the facilities architect to provide records. At 5:00 p.m., records were not provided for the approval to seal the cross-corridor separation doors.

Based on observation and document review, the facility failed to maintain and test the battery operated emergency lights located in the generator room, utilization room and community conference room. Failure to ensure the batter operated lights function and are tested routinely in accordance with 7.9, could result in potential harm to all residents and staff members, should the generator fail to function and the battery operated lights fail to function.

NFPA 101, 2000 Edition
7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30
seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration
of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

Findings:

During a tour of the facility, on 4/19/10, battery operated lights were observed in the generator room, the utilization management office and the community conference room.
During document review on 4/20/10, at 4:10 p.m., the facility failed to provide documentation that showed a 30 second monthly test and a 1 1/2 hour annual test was conducted on the 3 battery operated lights.

Based on observation, and record review, the facility failed to maintain battery operated exit signs in accordance with 7.9.1.3., and 7.9. This was evidenced by a lack of documentation for monthly and annual testing of its battery powered emergency exit signs and providing illuminated exit signs above exit doors.. This finding affected 3 of 9 smoke compartments. Failure to maintain and test emergency exit signs could potentially result in delayed evacuation and/or injury in the event of an emergency.


As evidence by:
NFPA 101, 2000 Edition:
7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code?.
7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30
seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration
of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed
at 30-day intervals.


Findings:

1. During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 11:06 a.m., the exit sign provided above the exit door located inside the kitchen was observed. The sign was a red and white paper sign and was not illuminated.
b) At 11:30 a.m., the exit sign provided above the exit door located inside the cafeteria leading to the east hallway was observed. The sign was a red and white paper sign and was not illuminated.

2. During record review, on 4/20/10, at 4:00 p.m., the facility failed to provide documentation for the monthly 30 second test and the 1 1/2 hour annual testing of the 2 batter powered exit signs located in the PHP unit.

Based on document review and staff interview, the facility failed to conduct disaster drills twice per year, ensuring all staff members are in-serviced and/or participate and sign in, as evidence by 11-5.3.9. Failure to conduct semi-annual disaster drills and provide training to all staff members to ensure staff members have knowledge of what to do if a disaster should occur could result in potential harm and/or the death to all residents and/or all staff members.


As evidence by:
NFPA 99, 1999 Edition:
11-5.3.9* Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.


Findings:


During record review, on 4/20/10, at 12:35 p.m., disaster drill records were reviewed. The following deficiencies were observed:
a) The facility failed to conduct semi-annual disaster drills. The facility conducted simulated disaster drills on 6/6/09 and 9/28/09, and on 10/26/09 a power outage occurred and was documented.
b) The facility failed to provide sign in sheet for all staff members who participated in the disaster drills. All staff members are to be in-serviced and participate semi-annual in a disaster drill and the facility must provide documentation of such training.

Based on record review, the facility failed to conduct and/or document simulated fire drills one per quarter, per shift. 12 of 12 fire drill records provided did not have sign in sheets for all staff on duty during the fire drill. The fire drill record forms provided were not completed. Failure to conduct fire drills one per quarter, per shift and ensure fire drill forms are filled out and staff participation is accounted for could result in potential harm to 61 of 61 residents and all staff members should a staff member be untrained in their roles and responsibilities during a fire.

Findings:

During record review, and staff interview, on 4/20/10, at 10:30 a.m., the fire drill records were reviewed. The following deficiencies were observed:
a) Fire drill records were reviewed. 12 of 12 fire drill records did not have all staff on duty, including non patient care staff members who respond to the fire drill location, signed in on the fire drill sign in sheet.
b) Documentation for the a.m., shift fire drill conducted on 4/30/09 was reviewed, the PHP unit "Fire Drill/Emergency exercise observation form", was not filled out.
c) Documentation for the a.m., shift fire drill conducted on 4/30/09 was reviewed, 1 of 2 competency tests attached to the fire drill report was not filled out by unit 3/4 staff members.
d) Documentation for the n.o.c., shift fire drill conducted on 10/10/09, was reviewed, 1 of 2 competency tests attached to the fire drill report was not completed by unit 3 staff members.
e) Documentation for the a.m., shift fire drill conducted on 10/14/09, was reviewed, 3 of 3 competency tests attached to the fire drill report were not filled out by unit 1 staff members.
f) Documentation for the p.m., shift fire drill conducted on 11/30/09, was reviewed, 2 of 2 competency tests attached to the fire drill report was not filled out by unit 3/4 staff members.
g) Documentation for the n.o.c., shift fire drill conducted on 12/29/09, was reviewed, 2 of 2 competency tests attached to the fire drill report was not filled out by unit 1 staff members.
h) Documentation for the n.o.c., shift fire drill conducted on 12/29/09, was reviewed, 2 of 2 competency tests attached to the fire drill report was not filled out by unit 2 staff members.
i) Documentation for the n.o.c., shift fire drill conducted on 12/29/09, was reviewed, 2 of 2 competency tests attached to the fire drill report was not filled out by unit 3/4 staff members.
j) Documentation for the a.m., shift fire drill conducted on 1/7/10, was reviewed, 1 of 2 competency tests attached to the fire drill report was not filled out by unit 3/4 staff members.
k) Documentation for the p.m., shift fire drill conducted on 2/25/10, was reviewed, unit 1"Fire Drill/Emergency exercise observation form", was not filled out.
l) Documentation for the p.m., shift fire drill conducted on 2/25/10, was reviewed, PHP unit "Fire Drill/Emergency exercise observation form", was not filled out.

Based on observation, the facility failed to maintain the fire alarm system and fire alarm system devices to ensure the system and all devices attached to the fire alarm system function properly. Failure to maintain the fire alarm system and fire alarm system devices could result in potential harm to all residents and staff, if the fire alarm system and/or fire alarm system devices fail to function.

Findings:During a test of the fire alarm system, on 4/20/09, the following deficiencies were observed at the following times and locations:
a) At 9/43 a.m., the fire alarm manual pull station located above the desk, nursing station unit 2 was observed obstructed. A fax machine and binders obstructed the manual pull station.
b) At 10:50 a.m., the fire alarm system was tested. The chime/strobe located by room 106 failed to sound an audible alarm

Based on observation, the facility failed to maintain the sprinkler system and/or sprinkler system escutcheon plates. Sprinkler head escutcheon plates are to be tightly fitted to the ceiling. Failure to maintain the sprinkler system escutcheon could result in a sprinkler system malfunction. Malfunction of the sprinkler system could potentially affect 9 of 9 smoke compartments.

Findings:

During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 10:54 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in the bathroom by the consult room, unit 1.
b) At 11:00 a.m., a 1/4 in. gap was observed around 1 of 4 sprinkler escutcheon plates located in the group locker room.
c) At 11:08 a.m., a 1/2 in. gap was observed around 1of 2 sprinkler escutcheon plates located in the dietary dry food storage room.
d) At 11:14 a.m., a 1/2 in. gap was observed around 3 of 4 sprinkler escutcheon plates located in the corridor outside of the dietary department.
e) At 11:18 a.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in corridor outside of unit 2 dayroom.
f) At 11:19 a.m., a 1/4 in. gap was observed around the sprinkler escutcheon plate located in the corridor outside of the day room, unit 2.
g) At 11:30 a.m., a 1/4 in. gap was observed around the sprinkler escutcheon plate located in janitor's closet by room 404.
h) at 11:41 a.m., 1/4 in. gap was observed around the sprinkler escutcheon plate located in the corridor outside of the linen storage closet, non-patient corridor.
i) At 2:15 p.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in the janitor's closet by room 109.
j) At 2:20 p.m., a 1/2 in. gap was observed around the sprinkler escutcheon plate located in the corridor outside of the patient article closet, unit 2.

Based on observation, the facility failed to maintain, and utilize the receptacles and/or building electrical components safely, as evidence by NFPA 70 400-8 and 240-4, and HCFA transmittal notice 22-99. Failure to maintain, test and utilize all receptacles within the building could result in potential harm to 75 of 75 residents.


As evidence by:
NFPA 70, 400-8 1999 edition, Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceiling, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

NFPA 70, article 240-4 1999 edition, Protection of Flexible Cords and Fixture Wires.
Flexible cord, including tinsel cord and extension cords, and fixtures wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixtures wire shall be protected against overcurrent in accordance with its ampacity as specified in table 402-5. Supplementary overcurrent protection, as in section 240-10, shall be permitted to be an acceptable mean cor providing this protection.
(b) Supply cord of listed appliance or portable lamps. Where flexible cord or tinsel cord is approved for and used with specific listed appliance or portable lamp, it shall be permitted to be supplied by a branch circuit of Article 210.
Also, HCFA transmittal notice 22-99, prohibits the use of extension cords without overcurrent protection (surge protectors).


Findings:

During a tour of the facility, on 4/19/10, the following deficiencies were observed at the following times and locations:
a) At 10:45 a.m., a computer on wheels (COW) was observed stored in the corridor. The electrical cord for the cow was observed running through the door to a bathroom and plugged into the bathroom outlet, located by unit 1 nursing station.
b) At 11:20 a.m., a microwave and a refrigerator were observed plugged into a surge protector, social service office.
c) At 12:20 p.m., a coffee pot and microwave was observed plugged into a surge protector, admissions office.