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Based on documentation review, observation and staff interview, the facility failed to ensure the life safety measures were following the National Fire Protection Association 101, 2012 Edition, Chapter 19 Existing Health Care Occupancies and Chapter 39 Existing Business Occupancies. The facility failed to ensure suite room doors closed properly (K200). The facility failed to ensure exit signs illuminated (K293). The facility failed to ensure doors in vertical openings closed and latched shut (K311). The facility failed to ensure the hazardous room door latch disabled (K321). The facility failed to ensure no sprinkler heads were missing (K351). The facility failed to ensure construction of the smoke/fire barriers (K372). The facility failed to ensure smoke/fire barrier doors were smoke resistant (K374). The facility failed to ensure transmission times of fire drills were documented (K712). The facility failed to have remote annunciator panels for generators (K916). The facility failed to ensure hazardous room doors were equipped with a self-closing device (K223). The facility failed to ensure emergency lights illuminated when tested (K291). The facility failed to have sensitivity testing of the smoke detectors (K345).

Based on observation, document review and staff interview, the facility failed to meet the provisions of the 2012 edition of the National Fire Protection Association 101, Life safety Code, Chapters 19 Existing Health Care Occupancies and Chapter 39 Existing Business Occupancies. This had the potential to affect all patients receiving services from the facility .

Findings include:

K 200 Suite room doors failed to close properly.

K 223 Hazardous room door not equipped with a self-closing device.

K 291 Emergency light failed to illuminate when tested.

K 293 Exit sign failed to illuminate.

K 311 Doors in vertical openings failed to close and latch shut

K 321 Hazardous room door latch disabled.

K 345 No sensitivity testing of the smoke detectors.

K 351 Sprinkler head missing in the refrigerator/freezer of the kitchen area.

K 372 Construction of the smoke/fire barriers not met.

K 374 Smoke/fire barrier doors are not smoke resistant.

K 712 Transmission times of fire drills not documented.

K 916 No remote annunciator panels for generators.

Based on observation and staff interview, the facility failed to ensure opened, partially used food items were labeled with the date of opening. This had the potential to affect all patients receiving nourishment from dietary services. The census was 12.

Findings include:

Observation on 11/14/17 at approximately 11:02 AM during a tour of the kitchen revealed an opened, partially used pack of cherrywood ham and icing in a bowl covered with plastic in the catering refrigerator. Neither item was labeled with the date of when they were opened. Further observation in the kitchen of the cook's freezer revealed undated, opened, partially used white bread and six pancakes. Additional observation in the kitchen revealed a bag of opened and undated granola and a bag of opened, undated graham cracker crumbs. These findings were verified at that time with Staff D, who stated, "Opened food items should be labeled with the date opened."

A policy was requested on 11/14/17 at 11:10 AM, but the policy was not provided prior to exit on 11/16/17.