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Based on visual observation the facility failed to assure that all doors within an exit passageway were held open by an approved means. When doors to stairwells, smoke barriers, horizontal exits or hazardous areas are propped open it provides an opportunity to allow fire and/or smoke to flow freely throughout the facility. This deficient practice has the potential to affect 18 of 18 residents.

Findings:

During the facility tour on 1/11/2017, between the hours of 8:30a-4:00p boservation revealed smoke barrier door located by the lab did not release with the activation of the fire alarm.

Interview with Administrator revealed the facility was not aware that the door would not release.

Based on visual observation the facility failed to provide sensitivity testing on the building smoke detectors that are connected to the fire alarm system. The detectors offer a means of activating the fire alarm system to provide emergency notification to the occupants of the building. This deficiency has the potential to affect 18 of 18 residents.

Findings:

During the facility tour on 1/11/2017, between the hours of 8:30a-4:00p observation revealed smoke sensitivity test had not been performed on the smoke detectors. Observation also revealed the smoke detector located at the door in Rehab wsa <3' from the air diffusor.

Interview with Administrator revealed the facility was not aware that the sensitivity testing of the smoke detectors is delinquent. During the exit interview this was also acknowledged by the Administrator.

Based on visual observation the facility failed to assure that the gas and vacuum piped system was inspected and tested in accordance with the requirements of NFPA 99. Activation of the system will provide needed oxygen to patients, which results in protection of life. This deficiency has the potential to affect 18 of 18 residents.

Findings:

During the facility tour on 1/11/2017, between the hours of 8:30a-4:00p observation revealed the last annual inspection on the gas and vacuum piped system was conducted on 11/5/2016

Interview with Administrator revealed the facility was not aware that the annual inspections had not been conducted on the gas and vacuum piped system.

Based on visual observation, the facility failed to comply with the requirements of NFPA 99 and other applicable codes with regard to electrical systems. In cases of a failure in the electrical systems this could have a detrimental affect on the life safety of the occupants. The deficient practice had the potential to affect 18 of 18 residents.

Findings:

During the facility tour on 1/11/2017, between the hours of 8:30a-4:00p observation revealed no emergency stop provided for the emergency generator that is located remote of the generaaat per NFPA 99, NFPA 110 & NFPA 70.

Interview with Administrator revealed the facility was not aware that these electrical system components were not provided.