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On the day of the recertification survey, based on observations and staff interview, the facility failed to ensure that the interior finish for rooms and spaces were being maintained in accordance with 19.3.3.1, 19.3.3.2. This deficient practice has the potential to effect all staff and residents in the area.

Findings include:

Observation on 2-19-2014 revealed that:

At 1:56 PM the interior wall of the business office behind the corridor door had a 1 inch by 2 inch penetration from the door handle. This condition was validated with the maintenance director and housekeeping supervisor at the time of discovery.

During the Exit Conference on 2-19-2014 at 2:50 P.M., the above condition was confirmed with the maintenance director and housekeeping supervisor.

On the day of the recertification survey, based on review of records and staff interview, the facility failed to ensure that the fire drills were being performed in accordance with 19.7.1.2. This deficient practice has the potential to effect all staff, residents and visitors.

Findings include:

Observation on 2-19-2014 revealed that:

1. No documentation was provided showing an AM fire drill was conducted for the first quarter of 2013.

2. No documentation was provided showing an AM fire drill was conducted for the second quarter of 2013.

3. No documentation was provided showing a PM fire drill was conducted for the third quarter of 2013.

4. No documentation was provided showing a PM fire drill was conducted for the fourth quarter of 2013.

. This condition was validated with the maintenance director at the time of discovery.

During the Exit Conference on 2-19-2014 at 2:50 P.M., the above condition was confirmed with the maintenance director and housekeeping supervisor.

On the day of the recertification survey, based on observations and staff interview, the facility failed to ensure that the cooking facilities were being maintained in accordance with 9.3.2, 19..3.2.6, NFPA 96.

This deficient practice has the potential to effect all staff and residents in the area.

Findings include:

Observation on 2-19-2014 revealed that:

At 2:04 PM:
1. Two of seven rubber caps on the discharge nozzles of the fixed hood extinguishing system were missing.

2. Three of seven discharge nozzles of the fixed hood extinguishing system were not aimed properly.

These conditions were validated with the maintenance director and housekeeping supervisor at the time of discovery.

During the Exit Conference on 2-19-2014 at 2:50 P.M., the above condition was confirmed with the maintenance director and housekeeping supervisor.

On the day of the recertification survey, based on observations and staff interview, the facility failed to ensure that the alcohol based hand rub dispensers were being maintained in accordance with 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623.

This deficient practice has the potential to effect all staff and residents in the area.

Findings include:

Observation on 2-19-2014 revealed that:

At 1:36 PM Alcohol Based Hand Rub dispensers in multiple rooms through out the facility were mounted to close to wall light sockets. This condition was validated with the maintenance director and housekeeping supervisor at the time of discovery.

During the Exit Conference on 2-19-2014 at 2:50 P.M., the above condition was confirmed with the maintenance director and housekeeping supervisor.

On the day of the recertification survey, based on observations and staff interview, the facility failed to ensure that the interior finish for rooms and spaces were being maintained in accordance with 19.3.3.1, 19.3.3.2. This deficient practice has the potential to effect all staff and residents in the area.

Findings include:

Observation on 2-19-2014 revealed that:

At 1:56 PM the interior wall of the business office behind the corridor door had a 1 inch by 2 inch penetration from the door handle. This condition was validated with the maintenance director and housekeeping supervisor at the time of discovery.

During the Exit Conference on 2-19-2014 at 2:50 P.M., the above condition was confirmed with the maintenance director and housekeeping supervisor.

On the day of the recertification survey, based on review of records and staff interview, the facility failed to ensure that the fire drills were being performed in accordance with 19.7.1.2. This deficient practice has the potential to effect all staff, residents and visitors.

Findings include:

Observation on 2-19-2014 revealed that:

1. No documentation was provided showing an AM fire drill was conducted for the first quarter of 2013.

2. No documentation was provided showing an AM fire drill was conducted for the second quarter of 2013.

3. No documentation was provided showing a PM fire drill was conducted for the third quarter of 2013.

4. No documentation was provided showing a PM fire drill was conducted for the fourth quarter of 2013.

. This condition was validated with the maintenance director at the time of discovery.

During the Exit Conference on 2-19-2014 at 2:50 P.M., the above condition was confirmed with the maintenance director and housekeeping supervisor.

On the day of the recertification survey, based on observations and staff interview, the facility failed to ensure that the cooking facilities were being maintained in accordance with 9.3.2, 19..3.2.6, NFPA 96.

This deficient practice has the potential to effect all staff and residents in the area.

Findings include:

Observation on 2-19-2014 revealed that:

At 2:04 PM:
1. Two of seven rubber caps on the discharge nozzles of the fixed hood extinguishing system were missing.

2. Three of seven discharge nozzles of the fixed hood extinguishing system were not aimed properly.

These conditions were validated with the maintenance director and housekeeping supervisor at the time of discovery.

During the Exit Conference on 2-19-2014 at 2:50 P.M., the above condition was confirmed with the maintenance director and housekeeping supervisor.