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Based on observation and interview with facility staff the facility failed to ensure 5 of 10 hazardous room doors will resist the passage of smoke. In the event of a fire all residents and staff may be affected.

Findings Include:

On 11-04-14 between 10:00a.m. and 1:00p.m. observation revealed the storage rooms on B and C wing and the clean linen storage room doors are not self closing. Observation also revealed the laundry room doors in the Mental Health unit are not positive latching.

Staff member M comfirmed the findings at the time of dicsovery.

Based on observation and interview with facility staff the facility failed to ensure exits are readily accessible at all times. In the event of a fire all residents and staff may be affected.

Findings Include:

On 11-04-14 between 10:00a.m. and 1:00p.m. observation revealed the exits on B and C wingat the common areas, the doctors office exit, and the exit at the end of C wing are not provided with an all weather surface to a public way. Observation also revealed the resident doors on the Mental Health unit are provided with multiple locking/latching devices.

Staff member M confirmed the findings at the time of discovery.
(NOTE) Staff member M was instructed to remove the additional door locks/latches immediately.

Based on record review and interview with facility staff the facility faciled to ensure proper testing of the buildings emergency light system. All residents and staff may be affected should the emergency lights fail in the event of a loss of power.

Findings Include:

On 11-04-14 at approximately 11:00a.m. record review revealed there was no documentation of annual 90 minute emergency light testing.

Staff member M confirmed the findings at the time of discovery.

Based on record review and interview with facility staff the facility failed to ensure proper testing of the building fire alarm system. All residents and staff may be affected should the fire alarm fail in the event of a fire.

Findings Include:

On 11-04-14 at approximately 11:29a.m. record review revealed there was no documented monthly fire alarm tests in the past 12 month period.

Staff member M confirmed the findings at the time of discovery.

Based on record review wand interview with facility staff the facility failed to ensure proper testing of the facilities smoke detection system. All residents and staff may be affected should the smoke detectors fail in the event of a fire.

Findings Include:

On 11-04-14 at approximately 10:30 a.m. record review revealed smoke detector sensitivity testing has not been performed in the past 2 years.

Staff member M confirmed the findings at the time of discovery.

Based on observation and interview with facility staff the facility failed to ensure 5 of 10 hazardous room doors will resist the passage of smoke. In the event of a fire all residents and staff may be affected.

Findings Include:

On 11-04-14 between 10:00a.m. and 1:00p.m. observation revealed the storage rooms on B and C wing and the clean linen storage room doors are not self closing. Observation also revealed the laundry room doors in the Mental Health unit are not positive latching.

Staff member M comfirmed the findings at the time of dicsovery.

Based on observation and interview with facility staff the facility failed to ensure exits are readily accessible at all times. In the event of a fire all residents and staff may be affected.

Findings Include:

On 11-04-14 between 10:00a.m. and 1:00p.m. observation revealed the exits on B and C wingat the common areas, the doctors office exit, and the exit at the end of C wing are not provided with an all weather surface to a public way. Observation also revealed the resident doors on the Mental Health unit are provided with multiple locking/latching devices.

Staff member M confirmed the findings at the time of discovery.
(NOTE) Staff member M was instructed to remove the additional door locks/latches immediately.

Based on record review and interview with facility staff the facility faciled to ensure proper testing of the buildings emergency light system. All residents and staff may be affected should the emergency lights fail in the event of a loss of power.

Findings Include:

On 11-04-14 at approximately 11:00a.m. record review revealed there was no documentation of annual 90 minute emergency light testing.

Staff member M confirmed the findings at the time of discovery.

Based on record review and interview with facility staff the facility failed to ensure proper testing of the building fire alarm system. All residents and staff may be affected should the fire alarm fail in the event of a fire.

Findings Include:

On 11-04-14 at approximately 11:29a.m. record review revealed there was no documented monthly fire alarm tests in the past 12 month period.

Staff member M confirmed the findings at the time of discovery.

Based on record review wand interview with facility staff the facility failed to ensure proper testing of the facilities smoke detection system. All residents and staff may be affected should the smoke detectors fail in the event of a fire.

Findings Include:

On 11-04-14 at approximately 10:30 a.m. record review revealed smoke detector sensitivity testing has not been performed in the past 2 years.

Staff member M confirmed the findings at the time of discovery.