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Tag No.: K0017
Based on observation and testing, the facility failed to provide Corridors that were separated from use areas by walls constructed with at least 1/2 hour fire resistance rating.
Findings include:
While inspecting corridor walls on August 21, 2012 at 11:35 a.m., the surveyor observed penetrations in the following locations above the ceiling:
1). In the old nursing home corridor just past the smoke barrier wall.
2). In corridor next to medical records.
3). In the corridor in front of the service corridor.
4). In the corridor wall just past the elevator.
These deficient practices have the potential of effecting the entire facility.
The maintenance supervisor and the administrator were notified during an exit conference.
Tag No.: K0039
Based on observation, the facility failed to provide clear and unobstructed corridors serving as exit access.
Findings Include:
While inspecting the width of aisles or corridors on August 21, 2012 at 12:35 p.m., the surveyor observed two hospital beds being stored in the clinic corridor.
These deficient practices have the potential of effecting 1 of 5 exits.
The maintenance supervisor and the administrator were notified during an exit conference.
Tag No.: K0052
Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system in accordance with NFPA 72 Section 1-5.6
Findings include:
While looking at test records on August 21, 2012 at 12:45 p.m., the surveyor could not find documentation the the fire alarm had its annual test in the last 12 months. The maintenance supervisor stated that the company the did their fire alarm testing has been running behind.
These deficient practices have the potential of effecting the entire facility.
The maintenance supervisor and the administrator were notified during an exit conference.
Tag No.: K0062
Based on observation and record review, the facility failed to properly test and maintained the automatic sprinkler system in accordance with NFPA 13, NFPA 25.
Findings include:
While looking at test records on August 21, 2012 at 12:45 p.m., the facility was unable to provide documentation the the sprinkler system had been tested at the annual level in the last 12 months. The maintenance supervisor stated that the company the did their fire alarm testing has been running behind.
These deficient practices have the potential of effecting the entire facility.
The maintenance supervisor and the administrator were notified during an exit conference.