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Based on observations and interview the facility failed to provide self-closing devices on doors used as storage room and failed to ensure hazard area ' s doors would positive latch within the door frame. These deficient practices would allow smoke and fire to spread within the exit corridor and affected all occupants. The facility census was 10 patients.

Findings are:
Observations on 10-20-15 between 11:10 am and 1:30 pm revealed:
1. Operating Room 6 was being used as a storage room, the doors failed to provide latching devices.
2. The elevator equipment #2 room failed to positive latch within the door frame when closed.

During an interview 10-20-15 between 11:10 am and 1:30 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
18.3.2.1* Hazardous Areas. Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

Based on observation and staff interview, the facility failed to maintain the exits so that no more than 30 pounds of pressure would set the doors in motion in 1 of 5 exits on second floor. This deficient practice has the potential to prevent occupants from exiting the facility during an emergency, which would affect all residents in 1 of 2 floors. Facility census was 10 residents.

Findings are:

Observation on 10-20-15 at 11:15 am revealed, while using a door pressure gauge to open the exit on the patio that leads to the fire lane, the force required to set the door in motion exceeded the maximum 35 pound limit of the gauge.

During an interview on 10-20-15 at 11:15 am, Maintenance A confirmed all the findings and the use of a door pressure gauge.

NFPA Standard

7.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release
the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.

Based on observation and staff interview the facility failed to have the fire alarm system maintained in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke and delay the notification of emergency responders, which would affect all residents. Facility census was 10.

Findings are:

Observation of the fire alarm panel on 10-20-15 at 11:22 am revealed the fire alarm panel was in trouble. The panel stated, " Card 8, SDACT Card is missing "

During an interview 10-20-15 at 11:22 am, observations were acknowledged and verified by Maintenance A.

Based on observation and staff interview, the facility allowed ceiling tiles to be missing were the fire sprinkler system was installed in the ceiling tile grid. This deficient practice would allow fire and smoke to fill in the cavity above the ceiling tiles delaying or preventing the fire sprinkler to extinguish a fire affecting all residents, visitors, and staff in 1 of 2 floors. The facility census was 10 residents.

Findings are:

Observation 10-20-15 at 11:38 am revealed a 1 ' x 4 ' ceiling tile was missing in the Janitor Closet in Post Op.

During an interview on 10-20-15 at 11:38 am, observations were acknowledged and verified by Maintenance A.

Based on observations and interview the facility failed to provide self-closing devices on doors used as storage room and failed to ensure hazard area ' s doors would positive latch within the door frame. These deficient practices would allow smoke and fire to spread within the exit corridor and affected all occupants. The facility census was 10 patients.

Findings are:
Observations on 10-20-15 between 11:10 am and 1:30 pm revealed:
1. Operating Room 6 was being used as a storage room, the doors failed to provide latching devices.
2. The elevator equipment #2 room failed to positive latch within the door frame when closed.

During an interview 10-20-15 between 11:10 am and 1:30 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
18.3.2.1* Hazardous Areas. Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

Based on observation and staff interview, the facility failed to maintain the exits so that no more than 30 pounds of pressure would set the doors in motion in 1 of 5 exits on second floor. This deficient practice has the potential to prevent occupants from exiting the facility during an emergency, which would affect all residents in 1 of 2 floors. Facility census was 10 residents.

Findings are:

Observation on 10-20-15 at 11:15 am revealed, while using a door pressure gauge to open the exit on the patio that leads to the fire lane, the force required to set the door in motion exceeded the maximum 35 pound limit of the gauge.

During an interview on 10-20-15 at 11:15 am, Maintenance A confirmed all the findings and the use of a door pressure gauge.

NFPA Standard

7.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release
the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.

Based on observation and staff interview the facility failed to have the fire alarm system maintained in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke and delay the notification of emergency responders, which would affect all residents. Facility census was 10.

Findings are:

Observation of the fire alarm panel on 10-20-15 at 11:22 am revealed the fire alarm panel was in trouble. The panel stated, " Card 8, SDACT Card is missing "

During an interview 10-20-15 at 11:22 am, observations were acknowledged and verified by Maintenance A.

Based on observation and staff interview, the facility allowed ceiling tiles to be missing were the fire sprinkler system was installed in the ceiling tile grid. This deficient practice would allow fire and smoke to fill in the cavity above the ceiling tiles delaying or preventing the fire sprinkler to extinguish a fire affecting all residents, visitors, and staff in 1 of 2 floors. The facility census was 10 residents.

Findings are:

Observation 10-20-15 at 11:38 am revealed a 1 ' x 4 ' ceiling tile was missing in the Janitor Closet in Post Op.

During an interview on 10-20-15 at 11:38 am, observations were acknowledged and verified by Maintenance A.