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Based on observations made on January 15, 2013, the facility failed to assure that a resident room door was not capable of being locked.

The findings include:

Locks shall not be permitted on resident sleeping room doors per section 19.2.2.2.2 of the Life Safety Code.

Room 105 was examined at 10:25 a.m. on January 15, 2013. The room at the time of the survey was a patient sleeping room. Previously the room had been an office and a deadbolt lock had been installed. The deadbolt lock was exercised and found to be still active and could be engaged to lock the room. With the change of use of this room to a patient sleeping room the deadbolt lock must be removed or disabled.

Based on observations made on January 15, 2013, the facility failed to assure that a sidewall sprinkler was located at the bottom of an elevator hoistway that was serviced by a hydraulic operating system.

The findings include:

Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 feet above the floor of the pit per section 5-13.6.1 of NFPA 13, 1999 Edition. Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

The elevator in the facility was examined at 11:04 a.m. on January 15, 2013. The elevator is serviced by a hydraulic operating system that utilizes hydraulic fluids. No sidewall sprinkler was located at the bottom of the elevator hoistway as required by NFPA 13.

Based on observations made on January 15, 2013, the facility failed to assure that verification collars were placed on fire extinguishers in accordance with NFPA 10, 1998 Edition.

The findings include:

Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a "Verification of Service" collar located around the neck of the container. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch per section 4-4.4.2 of NFPA 10.

The facility had fire extinguishers on loan from the extinguisher service company located within the two portions of the building at the time of the survey. Any extinguisher in readiness or in use in the facility must fully meet the requirements of NFPA 10. Both of the following extinguishers did not have a verification collar attached although they did have a metallic label (as required by 4-4.4.1 of NFPA 10) for the service performed. Both the metallic label and the verification collar are required.

1. The extinguisher in the elevator room, which had a six-year inspection performed in 2009, did not have a verification collar on it attesting to that fact as observed at 10:32 a.m. on January 15, 2013.

2. The extinguisher in the corridor outside of the kitchen, which had a six-year inspection performed in 2009, did not have a verification collar on it attesting to that fact as observed at 10:47 a.m. on January 15, 2013.

Based on observations made on January 15, 2013, the facility failed to assure that verification collars were placed on fire extinguishers in accordance with NFPA 10, 1998 Edition.

The findings include:

Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a "Verification of Service" collar located around the neck of the container. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch per section 4-4.4.2 of NFPA 10.

The facility had fire extinguishers on loan from the extinguisher service company located within the two portions of the building at the time of the survey. Any extinguisher in readiness or in use in the facility must fully meet the requirements of NFPA 10. The following extinguisher did not have a verification collar attached although they did have a metallic label (as required by 4-4.4.1 of NFPA 10) for the service performed. Both the metallic label and the verification collar are required.

The extinguisher by room 114, which was hydrotested in 2009, did not have a verification collar on it attesting to that fact as observed at 9:30 a.m. on January 15, 2013.

Based on observations made on January 15, 2013, the facility failed to maintain the electrical system and/or its components in accordance with the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Flexible cords and cables shall be connected to devices and to fittings so that tension will not be
transmitted to joints or terminals per Article 400-10 of NFPA 70.

1. A power strip was hanging loosely in room 115 as observed at 9:32 a.m. on January 15, 2013. The result was that tension was created on the flexible cords of the strip and the items attached to it. Note: The power strip was attached firmly to the wall to alleviate any flexible cord having tension on it and was confirmed by the surveyor while on-site.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.

2. A household type brown colored extension cord, without built-in circuit breaker protection, was in use in room 113 as observed at 9:35 a.m. on January 15, 2013. Note: The extension cord was removed from service and from the room after the observation was made and confirmed by the surveyor while on-site.

Based on observations made on January 15, 2013, the facility failed to maintain the electrical system and/or its components in accordance with the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Flexible cords and cables shall be connected to devices and to fittings so that tension will not be
transmitted to joints or terminals per Article 400-10 of NFPA 70.

1. A power strip was hanging loosely in the Laboratory office room as observed at 10:58 a.m. on January 15, 2013. The result was that tension was created on the flexible cords of the strip and the items attached to it. Note: The power strip was attached firmly to the wall to alleviate any flexible cord having tension on it and was confirmed by the surveyor while on-site.

Equipment intended to interrupt current at fault levels (Ground-Fault Circuit-Interrupter receptacles or GFCI) shall have an interrupting rating sufficient for the nominal circuit voltage and the current available at the line terminals of the equipment per Articles 110-3 and 110-9 of NFPA 70. Such equipment (GFCI receptacles) shall be listed or labeled and restore current when the test and reset buttons are exercised.

2. The GFCI receptacle in the bathroom of room 106 was tested at 10:17 a.m. on January 15, 2013. The receptacle did not break current either by use of the test button on the receptacle or by an independent testing instrument.

Based on observations made on January 15, 2013, the facility failed to assure that a resident room door was not capable of being locked.

The findings include:

Locks shall not be permitted on resident sleeping room doors per section 19.2.2.2.2 of the Life Safety Code.

Room 105 was examined at 10:25 a.m. on January 15, 2013. The room at the time of the survey was a patient sleeping room. Previously the room had been an office and a deadbolt lock had been installed. The deadbolt lock was exercised and found to be still active and could be engaged to lock the room. With the change of use of this room to a patient sleeping room the deadbolt lock must be removed or disabled.

Based on observations made on January 15, 2013, the facility failed to assure that a sidewall sprinkler was located at the bottom of an elevator hoistway that was serviced by a hydraulic operating system.

The findings include:

Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 feet above the floor of the pit per section 5-13.6.1 of NFPA 13, 1999 Edition. Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

The elevator in the facility was examined at 11:04 a.m. on January 15, 2013. The elevator is serviced by a hydraulic operating system that utilizes hydraulic fluids. No sidewall sprinkler was located at the bottom of the elevator hoistway as required by NFPA 13.

Based on observations made on January 15, 2013, the facility failed to assure that verification collars were placed on fire extinguishers in accordance with NFPA 10, 1998 Edition.

The findings include:

Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a "Verification of Service" collar located around the neck of the container. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch per section 4-4.4.2 of NFPA 10.

The facility had fire extinguishers on loan from the extinguisher service company located within the two portions of the building at the time of the survey. Any extinguisher in readiness or in use in the facility must fully meet the requirements of NFPA 10. Both of the following extinguishers did not have a verification collar attached although they did have a metallic label (as required by 4-4.4.1 of NFPA 10) for the service performed. Both the metallic label and the verification collar are required.

1. The extinguisher in the elevator room, which had a six-year inspection performed in 2009, did not have a verification collar on it attesting to that fact as observed at 10:32 a.m. on January 15, 2013.

2. The extinguisher in the corridor outside of the kitchen, which had a six-year inspection performed in 2009, did not have a verification collar on it attesting to that fact as observed at 10:47 a.m. on January 15, 2013.

Based on observations made on January 15, 2013, the facility failed to assure that verification collars were placed on fire extinguishers in accordance with NFPA 10, 1998 Edition.

The findings include:

Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a "Verification of Service" collar located around the neck of the container. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch per section 4-4.4.2 of NFPA 10.

The facility had fire extinguishers on loan from the extinguisher service company located within the two portions of the building at the time of the survey. Any extinguisher in readiness or in use in the facility must fully meet the requirements of NFPA 10. The following extinguisher did not have a verification collar attached although they did have a metallic label (as required by 4-4.4.1 of NFPA 10) for the service performed. Both the metallic label and the verification collar are required.

The extinguisher by room 114, which was hydrotested in 2009, did not have a verification collar on it attesting to that fact as observed at 9:30 a.m. on January 15, 2013.

Based on observations made on January 15, 2013, the facility failed to maintain the electrical system and/or its components in accordance with the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Flexible cords and cables shall be connected to devices and to fittings so that tension will not be
transmitted to joints or terminals per Article 400-10 of NFPA 70.

1. A power strip was hanging loosely in room 115 as observed at 9:32 a.m. on January 15, 2013. The result was that tension was created on the flexible cords of the strip and the items attached to it. Note: The power strip was attached firmly to the wall to alleviate any flexible cord having tension on it and was confirmed by the surveyor while on-site.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.

2. A household type brown colored extension cord, without built-in circuit breaker protection, was in use in room 113 as observed at 9:35 a.m. on January 15, 2013. Note: The extension cord was removed from service and from the room after the observation was made and confirmed by the surveyor while on-site.

Based on observations made on January 15, 2013, the facility failed to maintain the electrical system and/or its components in accordance with the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Flexible cords and cables shall be connected to devices and to fittings so that tension will not be
transmitted to joints or terminals per Article 400-10 of NFPA 70.

1. A power strip was hanging loosely in the Laboratory office room as observed at 10:58 a.m. on January 15, 2013. The result was that tension was created on the flexible cords of the strip and the items attached to it. Note: The power strip was attached firmly to the wall to alleviate any flexible cord having tension on it and was confirmed by the surveyor while on-site.

Equipment intended to interrupt current at fault levels (Ground-Fault Circuit-Interrupter receptacles or GFCI) shall have an interrupting rating sufficient for the nominal circuit voltage and the current available at the line terminals of the equipment per Articles 110-3 and 110-9 of NFPA 70. Such equipment (GFCI receptacles) shall be listed or labeled and restore current when the test and reset buttons are exercised.

2. The GFCI receptacle in the bathroom of room 106 was tested at 10:17 a.m. on January 15, 2013. The receptacle did not break current either by use of the test button on the receptacle or by an independent testing instrument.