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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.2.7, and 7.2.6

Findings include:

During a tour of the facility, the surveyor observed the path of egress to the public way, from the exit at room 114, was blocked by a car.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the exit signage per the requirements of:

2012 NFPA 101, 19.2.10.1, 7.10.1.2.2, and 7.10.2.1

This deficiency affects 1 of 5 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed the exit sign at the Nurses' Station had chevron-type indicators directing egress to the left and the right; the correct direction for emergency egress was straight thru the door.

A member of the maintenance staff was present when the deficiency was identified.

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Based on review of documentation, the facility failed to maintain the kitchen hood's automatic fire-extinguishing system per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 10.2.6 (4)
2009 NFPA 17A, 7.2.1, and 7.2.2

This deficiency affects the kitchen.

Findings include:

During a tour of the facility, the facility failed to provide the monthly inspections for the kitchen hood's automatic fire-extinguishing system. No documentation was provided. Maintenence said they were not aware of this requirement.

A member of maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the smoke detectors per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 14.4.5.3.2, Table 14.3.1(9)(h), 14.4.5, and Table 14.4.5

This deficiency affects 5 of 5 smoke compartments.

During a tour of the facility, the facility failed to provide the following documentation:

1. A smoke detector sensitivity test report completed within the past two years
2. Smoke detector semi-annual visual inspections for the past 12 months
3. An annual fire alarm inspection completed within the past 12 months

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 5.3.1.1.1.3, and 5.2.4.1

This deficiency affects the entire facility

Findings include:

During a tour of the facility, the facility failed to provide the following documentation:

1. The 2000 fast-response sidewall sprinkler heads that were found in the Front Lobby and Business Offices had been replaced or a representative sample tested within 20 years of installation.

2. The 2001 fast-response sprinkler heads that were found in the Front Lobby and Business Offices had been replaced or a representative sample tested within 20 years of installation.

3. The monthly inspections on the wet sprinkler riser gauges.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the permitted smoking area per the requirements of:

2012 NFPA 101, 19.7.4 (6)

This deficiency affects the smoking area.

Findings include:

During a tour of the facility, the surveyor observed the metal container with a self-closing cover device contained combustible trash, such as paper and cups, at the permitted smoking area.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to provide documentation that the residents' rooms cubicle curtains met the flame propagation criteria per the requirements of:

2012 NFPA 101, 19.7.5.1 (1), and 10.3.1

This deficiency affects 1 of 1 patient rooms with cubicle curtains.

Findings include:

During a tour of the facility, the surveyor observed the cubicle curtains in the only patient room that had them were not marked or identified as meeting the flame propagation criteria of NFPA 701. The facility failed to provide documentation that these cubicle curtains met the flame propagation criteria.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the testing of the emergency generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3
2010 NFPA 110, 8.3.7.1

This deficiency affects 1 of 1 generator.

Findings include:

During a tour of the facility, the facility failed to provide documentation of performing monthly conductance testing on the facility's emergency generator's maintenance-free battery for the past 12 months.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8
S&C: 14-46-LCS

This deficiency affects the Snack Room off of the Front Lobby.

Findings include:

During a tour of the facility, the surveyor observed the vending machines in the Snack Room off of the Front Lobby were plugged into an orange extension cord.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to ensure continuing education on the handling and risks associated with oxygen cylinders and other medical gases stored in cylinders per the requirements of:

2012 NFPA 99, 11.5.2.1

This deficiency affects all staff that handle oxygen cylinders and/or other medical gases stored in cylinders.

Findings include:

During a tour of the facility, the facility failed to provide documentation on the following:

1. The qualifications and training of the facility's training personnel on handling oxygen cylinders.

2. Continuing education for their personnel that handle oxygen cylinders

3. Training personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases on the risks associated with their handling and use.

4. A continuing education program for staff that handle oxygen cylinders to include periodic review of safety guidelines and usage requirements for medical gases and their cylinders.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

This deficiency affects the outside Oxygen Storage Room.

Findings include:

During a tour of the facility, the surveyor observed five unsecured oxygen cylinders in the outside Oxygen Storage Room at the back of the building.

A member of the maintenance staff was present when this deficiency was identified..