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Based on observation and interview with facility staff the facility failed ot ensure 7 of 7 smoke barrier doors will resist the passage of smoke. In the event of a fire all 25 residents may be affected.

Findings Include:

On 06-12-13 between 9:30 a.m. and 3:330p.m. observation revealed up to a 3/8 gap between double leaves of smoke barrier doors.

Staff member M confirmed the findings at the time of discovery.

Based on observation and interview with facility staff the facility failed to ensure doors to 3 of 15 hazardous areas are properly amintained. In the event of a fire administartive and housekeeping personal may be affected.

Findings Include:

On 06-12-13 between 9:30 a.m. and 3:30 p.m. observation revealed the housekeeping storage room door near the kitchen has a mail box attached to the door damaging the door , the Main electrical room door is missing its hardware and does not latch, and the Main electrical room door and the Emergency Electrical room doors are held open with unapproved door stops.

Staff member M confirmed the findings at the time of discovery.

Based on record review and interview with facility staff the facility failed to ensure disaster drills are conducted at required intervals. All clients and staff may be affected should staff be unaware of procedures during a disaster.

Findings Include:

On 06-12-13 at approximately 9:45a.m. record review revealed the facility conducted only one disaster drill in the past 12 month period.

Staff member M confirmed the findings at the time of discovery.

Based on record review and interview and with facility staff the facility failed to ensure the fire alarm system is properly tested, inspected, and maintained. All 25 clients may be affected should the fire alarm fail in the event of a fire.

Findings Include:

On 06-12-13 at approximately 11:00a.m. record review revealed annual fire alarm inspection, testing and maintenance has not been performed in the past 12 month period.

Staff member M confirmed the findings at the time of discovery.

Based on record review , observation, and interview with facility staff the facility failed to ensure proper inspection , testing and maintenance of the sprinkler system. All 25 clients may be affected should the sprinkler system fail in the event of a fire.

Findings Include:

On 06-12-13 between 9:30 a.m. and 3:30 p.m. record review revealed there was no quarterly sprinkler inspection and testing in the 2nd quarter. The annual sprinkler maintenance and testing records indicated the following deficiencies:
(a) Gauges have not been calibrated in the last 5 years.
(b) Water flow switches are not reporting to the fire alarm panel.
(c) Valve tags are missing from the risers.
(d) 5 year branch line investigation has not been performed.
(e) Water flow alarms did not function.

On 06-12-13 observation revealed the Fire Department Connection is not labeled and a wrench is not provided in the spare sprinkler cabinet.


Staff member M confirmed the findings at the time of discovery.

Based on observation and interview with facility staff the facility failed ot ensure 7 of 7 smoke barrier doors will resist the passage of smoke. In the event of a fire all 25 residents may be affected.

Findings Include:

On 06-12-13 between 9:30 a.m. and 3:330p.m. observation revealed up to a 3/8 gap between double leaves of smoke barrier doors.

Staff member M confirmed the findings at the time of discovery.

Based on observation and interview with facility staff the facility failed to ensure doors to 3 of 15 hazardous areas are properly amintained. In the event of a fire administartive and housekeeping personal may be affected.

Findings Include:

On 06-12-13 between 9:30 a.m. and 3:30 p.m. observation revealed the housekeeping storage room door near the kitchen has a mail box attached to the door damaging the door , the Main electrical room door is missing its hardware and does not latch, and the Main electrical room door and the Emergency Electrical room doors are held open with unapproved door stops.

Staff member M confirmed the findings at the time of discovery.

Based on record review and interview with facility staff the facility failed to ensure disaster drills are conducted at required intervals. All clients and staff may be affected should staff be unaware of procedures during a disaster.

Findings Include:

On 06-12-13 at approximately 9:45a.m. record review revealed the facility conducted only one disaster drill in the past 12 month period.

Staff member M confirmed the findings at the time of discovery.

Based on record review and interview and with facility staff the facility failed to ensure the fire alarm system is properly tested, inspected, and maintained. All 25 clients may be affected should the fire alarm fail in the event of a fire.

Findings Include:

On 06-12-13 at approximately 11:00a.m. record review revealed annual fire alarm inspection, testing and maintenance has not been performed in the past 12 month period.

Staff member M confirmed the findings at the time of discovery.

Based on record review , observation, and interview with facility staff the facility failed to ensure proper inspection , testing and maintenance of the sprinkler system. All 25 clients may be affected should the sprinkler system fail in the event of a fire.

Findings Include:

On 06-12-13 between 9:30 a.m. and 3:30 p.m. record review revealed there was no quarterly sprinkler inspection and testing in the 2nd quarter. The annual sprinkler maintenance and testing records indicated the following deficiencies:
(a) Gauges have not been calibrated in the last 5 years.
(b) Water flow switches are not reporting to the fire alarm panel.
(c) Valve tags are missing from the risers.
(d) 5 year branch line investigation has not been performed.
(e) Water flow alarms did not function.

On 06-12-13 observation revealed the Fire Department Connection is not labeled and a wrench is not provided in the spare sprinkler cabinet.


Staff member M confirmed the findings at the time of discovery.