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Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the corridor doors in accordance with NFPA 101. This deficient practice could affect no residents and all staff and visitors in 3 of 12 smoke zones. The facility has a capacity of 25 with a census of 6 residents at the time of survey.
Findings include:

During the survey conducted on 8/29/30 the following deficiencies are noted:

1. During the survey at approximately 3:00 PM it is observed that the smoke barrier doors near stairway D did not completely close and latch when tested.
2. During the survey at approximately 3:15 PM it is observed that the smoke barrier doors near clinic storage did not completely close and latch when tested.

Maintenance staff was present and acknowledged that the smoke barrier doors did not completely close and latch.

NFPA Standard: Doors in corridor walls of sprinkled buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinkled buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all residents, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 25 with a census of 6 residents at the time of the survey.
Findings include:

During the survey conducted on 08/29/16 the following deficiency is noted:

1. During document review between 12:00 PM and 1:30 PM it is observed that proper testing of the generator weekly inspections and run times has not been maintained. The documentation log showed missed weekly inspections in August 2015, September 2015, and August 2016.

Staff A was present and acknowledged the missed weekly inspections.


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

Based on observation, document review, and staff interview, the facility failed to properly inspect and maintain the corridor doors in accordance with NFPA 101. This deficient practice could affect no residents and all staff and visitors in 3 of 12 smoke zones. The facility has a capacity of 25 with a census of 6 residents at the time of survey.
Findings include:

During the survey conducted on 8/29/30 the following deficiencies are noted:

1. During the survey at approximately 3:00 PM it is observed that the smoke barrier doors near stairway D did not completely close and latch when tested.
2. During the survey at approximately 3:15 PM it is observed that the smoke barrier doors near clinic storage did not completely close and latch when tested.

Maintenance staff was present and acknowledged that the smoke barrier doors did not completely close and latch.

NFPA Standard: Doors in corridor walls of sprinkled buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinkled buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all residents, visitors, and staff in 12 of 12 smoke zones. The facility has a capacity of 25 with a census of 6 residents at the time of the survey.
Findings include:

During the survey conducted on 08/29/16 the following deficiency is noted:

1. During document review between 12:00 PM and 1:30 PM it is observed that proper testing of the generator weekly inspections and run times has not been maintained. The documentation log showed missed weekly inspections in August 2015, September 2015, and August 2016.

Staff A was present and acknowledged the missed weekly inspections.


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2