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Based on visual observation and record review the facility failed to assure routine cleanings were conducted on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 8 of 8residents.

Findings:

During the facility tour and record review on 11/17/22, between the hours of 8:00a-4:30p observation and record review revealed grease build-up on the hood system in the dining area.

Interview with maintenance revealed the facility was not aware the hood cleaning was not conducted on the hood suppression system.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke and fire from one compartment to the other in the facility. The deficient practice had the potential to affect 8 of 8 patients.


Findings:

During the facility tour on 11/16/22 between the hours of 8:00a-4:30p observation revealed the barrier throughout the facility were not properly constructed and sealed. Walls were sealed with "scab" type construction over large holes.

Interview with maintenance revealed the facility was not aware of walls not properly sealed.