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Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants. The deficient practice had the potential to affect 14 of 14 residents.
3 of 8 corridors had doors that were deficient.

Findings:

During the facility tour on 8/26/2015 observation revealed corridor doors would latch in the frame for: Room 203, Dining, Dishwashing Room, Rear Administration office and janitor closet across from room 217.

Interview with Maintenance Director revealed the facility was not aware of the door to these rooms were not latching in the frame or required to latch.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 0 of 14 residents.

Findings:

During the facility tour on 8/26/2015 observation revealed rear door to purchasing was not equipted with a closure


Interview with Maintenance Director revealed the facility was not aware that the doors to the hazardous areas were required to self-close and latch in the frame.

Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor 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 14 of 14 residents.

Findings:

During the record review and inspection, observation and record review revealed hood suppression system was inspected and yellow tagged on 8/4/2015

Interview with Maintenance Director revealed the facility was aware that the system was yellow tagged. Maintenance Director stated that hood suppression company ordered the bottles to correct the condition and will install as soon as they come in.

Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants. The deficient practice had the potential to affect 14 of 14 residents.
3 of 8 corridors had doors that were deficient.

Findings:

During the facility tour on 8/26/2015 observation revealed corridor doors would latch in the frame for: Room 203, Dining, Dishwashing Room, Rear Administration office and janitor closet across from room 217.

Interview with Maintenance Director revealed the facility was not aware of the door to these rooms were not latching in the frame or required to latch.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 0 of 14 residents.

Findings:

During the facility tour on 8/26/2015 observation revealed rear door to purchasing was not equipted with a closure


Interview with Maintenance Director revealed the facility was not aware that the doors to the hazardous areas were required to self-close and latch in the frame.

Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor 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 14 of 14 residents.

Findings:

During the record review and inspection, observation and record review revealed hood suppression system was inspected and yellow tagged on 8/4/2015

Interview with Maintenance Director revealed the facility was aware that the system was yellow tagged. Maintenance Director stated that hood suppression company ordered the bottles to correct the condition and will install as soon as they come in.