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Based on observations, the facility failed to properly protect hazardous areas. This condition had the potential to affect 100% of the residents and staff.

Findings Include:

On September 27, 2011 at 10:00 a.m., the maintenance person and surveyor found the Soiled Linen Room located near the Nurses Station, did not have an operational self-closing device.

This deficient practice had the potential of affecting the resident areas of the facility. The maintenance supervisor and the assistant administrator were notified during the exit conference.

Based on observation and record review, the facility failed to properly test and maintained the automatic sprinkler system contrary to NFPA 13, NFPA 25. This condition affected 100% of the residents and staff as all smoke compartments were affected.

Findings include:

On September 27, 2011 at 10:30 a.m., the facility could not provide documentation stating that they had perform the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

The maintenance supervisor and the assistant administrator were notified during an exit conference.

Based on observations, the facility failed to provide clear and unobstructed means of egress as directed in NFPA 101 chapter 7.1.10.1. This deficiency had the potential to affect 20% of the residents and staff.

Findings include:

On September 27, 2011 at 11:30 a.m., the maintenance person and the surveyor found that the exit located at the IOP were partially blocked with chairs and a table.

This deficient practice had the potential of affecting 1 of the 2 smoke compartments. The maintenance director and the assistant administrator were notified during the exit conference.

Based on observations, the facility failed to properly protect hazardous areas. This condition had the potential to affect 100% of the residents and staff.

Findings Include:

On September 27, 2011 at 10:00 a.m., the maintenance person and surveyor found the Soiled Linen Room located near the Nurses Station, did not have an operational self-closing device.

This deficient practice had the potential of affecting the resident areas of the facility. The maintenance supervisor and the assistant administrator were notified during the exit conference.

Based on observation and record review, the facility failed to properly test and maintained the automatic sprinkler system contrary to NFPA 13, NFPA 25. This condition affected 100% of the residents and staff as all smoke compartments were affected.

Findings include:

On September 27, 2011 at 10:30 a.m., the facility could not provide documentation stating that they had perform the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

The maintenance supervisor and the assistant administrator were notified during an exit conference.

Based on observations, the facility failed to provide clear and unobstructed means of egress as directed in NFPA 101 chapter 7.1.10.1. This deficiency had the potential to affect 20% of the residents and staff.

Findings include:

On September 27, 2011 at 11:30 a.m., the maintenance person and the surveyor found that the exit located at the IOP were partially blocked with chairs and a table.

This deficient practice had the potential of affecting 1 of the 2 smoke compartments. The maintenance director and the assistant administrator were notified during the exit conference.