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Based on observation and staff interview the facility fails to assure that the fire rated doors separating the central supply room from the corridor/surgery room are self/automatic closing doors in accordance with 19.2.2.2.6. This deficient practice could result in the passage of smoke from the central supply room into the corridor/surgery room areas, affecting 0 residents in 1 of 3 smoke zones. The facility has a capacity of 18 with a census of 5 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 4/2/13, between 10:00 a.m. and 2:30 p.m., the following is observed:

--1. The Southeast door to the central supply room is dragging on the frame and will not automatically latch.

--2. The Northeast door to the central supply room is not equipped with a self closing device or a positive latch.

Maintenance Staff A, B and C were present and acknowledged the findings.

NFPA Standard: Door openings in smoke barriers have at least a 20-minute fire protection rating or are at least 1?-inch thick solid bonded wood core. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Doors are self-closing or automatic closing in accordance with 19.2.2.2.6. Swinging doors are not required to swing with egress and positive latching is not required. 19.3.7.5, 19.3.7.6, 19.3.7.7

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting all residents in 3 of 3 smoke zones. The facility has a capacity 18 of with a census of 5 at the time of the survey.

Findings include:

During the tour conducted on 4/3/13, a review of records between 10:00 a.m. and 11:00 a.m. for the last 5 quarters revealed the following:

--1. There are 3 drills on the 1st shift conducted between 9:00 a.m. and 9:45 a.m., for the 1st and 3rd Qtrs of 2012.

--2. There are 2 drills on the 1st shift 4th Qtr of 2012 conducted at 1:20 p.m. and 1:57 p.m., and 2 more on the 1st shift 1st Qtr of 2013 conducted at 1:36 p.m. and 2:20 p.m..

--3. There are 4 drills on the 2nd shift from the 2nd Qtr of 2012 through the 1st Qtr of 2013 that are all conducted between 7:09 p.m. and 8:00 p.m..

Maintenance Staff A, B and C were present and acknowledged the results of the record review.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2