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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 0 residents.

Findings:

During the facility tour on 10/25/2017, between the hours of 9:00a-2:30p observation revealed a penetration in the wall by the door in the records storage room. Observation also revealed doors to office storage, storage by room 210, maintenance storage/office and mechanical room were not self-closing. Mechanical room also contained unnecsscary combustibles stored in this area.

Interview with Administrator revealed the facility was not aware of the walls of the hazardous areas having unsealed penetrations and doors to the hazardous areas were required to self-close and latch in the frame.

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 0 of 0 residents.


Findings:

During the facility tour on 10/25/2017, between the hours of 9:30a-2:30p observation revealed corridor doors to Human Resources and Registration did not latch in to the frame.

Interview with Administrator revealed the facility was not aware of the door to these room were not latching in the frame.

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 from one compartment to the other in the facility. The deficient practice had the potential to affect 0 of 0 residents.


Findings:

During the facility tour on 10/25/2017, between the hours of 9:30a-2:30p observation revealed barrier walls located on patient hall & hall by Ultrasound were not sealed from wall to wall.

Interview with Administrator revealed the facility was not aware of unsealed penetration.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 0 of 0 residents.
4 of 4 quarters in 2016-2017 were deficient.

Findings:

During the record review on 10/25/2017, between the hours of 9:30a-2:30p record review revealed 2 of 12 fire drills were documented for the past 12 months.

Interview with Administration revealed the facility was not aware fire drills were not being held and documented.

Based on visual observation the facility failed to assure that the gas and vacuum piped system was inspected and tested in accordance with the requirements of NFPA 99. Activation of the system will provide needed oxygen to patients, which results in protection of life. This deficiency has the potential to affect 0 of 0 residents.

Findings:

During the facility tour on 10/25/2017, between the hours of 9:30a-2:30p observation revealed no annual inspection was conducted on the gas and vacuum within the last year.

Interview with Administrator revealed the facility was not aware that the annual inspections had not been conducted on the gas and vacuum piped system.

Based on visual observation, the facility failed to comply with the requirements of NFPA 99 and other applicable codes with regard to electrical systems. In cases of a failure in the electrical systems this could have a detrimental affect on the life safety of the occupants. The deficient practice had the potential to affect 0 of 0 residents.

Findings:

During the facility tour on 10/25/2017, between the hours of 9:30a-2:30p observation revealed the 2 generators were not equipped with emergency stops that are located remote of the generators. Observation also revealed the generators did not have a trickle charger for the batteries and no fire extinguisher was located within 30' of the generators.

Interview with Administrator revealed the facility was not aware that these electrical system components were not provided.