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Based on observation and staff interview, the facility failed to provide doors with self-closing or automatic-closing in accordance with 19.2.2.2.6. This condition had the potential to affect about 50% (percent) of the residents and staff and the potential of affecting two (2) of six (6) smoke compartments.

Findings include:

On February 23, 2011 at approximately 11:30 a.m., while inspecting smoke barrier walls with the maintenance supervisor, observation revealed that a door in the smoke barrier wall located across from the kitchen lacked a door closure.

The administrator and maintenance director were notified during the survey and in the exit conference. No other information was offered by the facility.

Based on observation and testing, the facility failed to ensure hazardous areas were properly protected. This condition affected 25% of the residents and staff.

Findings include:

During a facility tour with the maintenance person on February 23, 2011 at 1:45 p.mobservation revealed that Rooms #214 and #215 were being used for combustible storage. The room doors did not have door closer installed.

Part 1

Based on observation and testing, the facility failed to provide a properly installed, tested and maintained fire alarm system in accordance with NFPA 70 and NFPA 72. This condition affected 25% of the residents and staff occupying one (1) of four (4) smoke compartments.

Findings include:

On February 23, 2011 at approximately 2:00 p.m., observation made with the maintenance person revealed that no horn/strobe was installed in the administration hallway.

The maintenance supervisor and the administrator were notified during an exit conference.

Part 2

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. This condition affected 100% of the residents and staff, as all smoke compartments were affected. NFPA 72, Section 1-5.6

Findings include:

On February 23, 2011 at approximately 2:30 p.m. observation made with the maintenance person revealed that the facility could not produce documentation stating that the fire alarm had been tested monthly.

The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation, the facility failed to maintain the required two (2) master alarm panels with audible and visible signals for the bulk oxygen system.

Finding include:

While inspecting the bulk oxygen system on February 23, 2011 at appromimately 12:40 p.m., observation revealed the facility had two (2) master alarm panels for the bulk oxygen system, however the audible and visual signals were not functioning properly.

This deficient practice had the potential of affecting all patients requiring oxygen on any given day.

The administrator and the maintenance director were notified during the survey, as well as the exit conference.