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Based on visual observation and record review the facility failed to assure that semi-annual inspections was 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 12 of 12 residents.

Findings:

During the record review, between the hours of 9:30 AM and 3:00 PM on 2/15/16, it was observed that the last semi-annual inspection on the kitchen hood suppression system was conducted on July 22, 2015.

Interview with administrator revealed the facility was not aware the semi-annual inspection was not conducted on the hoop suppression system.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier was filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. 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 12 of 12 residents.
1 of 2 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 9:00 AM and 3:00 PM on 2/15/16, it was observed that the West wing smoke barrier had an unsealed penetration.

Interview with administrator revealed the facility was not aware that the smoke barrier had a penetration that was not sealed.

Based on visual observation and record review the facility failed to assure that semi-annual inspections was 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 12 of 12 residents.

Findings:

During the record review, between the hours of 9:30 AM and 3:00 PM on 2/15/16, it was observed that the last semi-annual inspection on the kitchen hood suppression system was conducted on July 22, 2015.

Interview with administrator revealed the facility was not aware the semi-annual inspection was not conducted on the hoop suppression system.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier was filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. 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 12 of 12 residents.
1 of 2 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 9:00 AM and 3:00 PM on 2/15/16, it was observed that the West wing smoke barrier had an unsealed penetration.

Interview with administrator revealed the facility was not aware that the smoke barrier had a penetration that was not sealed.