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Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 8 of 8 residents.

Findings:

During the facility tour on 10/16/2015 observation revealed missing ceiling tiles in the 2nd floor shreader room across from Health Info Dir, 2nd floor Charting room, Pharmacy, Room 209, Room 203, Room 210.

Interview with Maintenance Director revealed the facility was not aware of the penetrations in the corridor walls and ceiling that would allow the transfer of smoke from one room to another.

Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants. The deficient practice had the potential to affect 5 of 8 residents.


Findings:

During the facility tour on 10/16/2015 observation revealed doors at following locations failed to latch in the frame: 3rd floor dietary kitchen, Room 221, 2nd floor storage #2 by elevator, 1st floor housekeeping, 1st floor sterilize room, chapel, x-ray, x-ray office and lab door.

Interview with Maintenance Director revealed the facility was not aware that these doors were required to latch in the frame.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 3 of 8 patients.

Findings:

During the facility tour on 10/16/2015 observation revealed doors for rooms converted to combustible storage room over 50 sq ft were not self-closing: Room 207, Room 213, Room 215, Room 221 and 3rd floor dump water room.


Interview with Maintenance Director revealed the facility was not aware that the rooms had been converted to storage roomsrequiring to self-close and latch in the frame.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. This deficiency has the potential to affect 8 of 8 residents.

Findings:

During the facility tour on 10/16/2015 observation revealed no sprinkler coverage in room 201 and 2nd floor corridor outside controller office.

Interview with Maintenance Director revealed the facility was not aware the automatic sprinkler system was not complete.

Based on visual observation, the facility failed to provide doors in accordance with NFPA 101:7.2.1. Multiple door releasing hardware creates a high risk of injury and/or death in delaying egress. The deficiency has the potential to affect staff of this facility.

Findings:

During the facility tour on 10/16/2015 observation revealed doors on the 2nd floor were equipped with more than one releasing mechanism.

Interview with Maintenance director revealed the facility was not aware that this was an issue.

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 8 of 8 residents.

Findings:

During the facility tour on 10/16/2015 observation revealed missing ceiling tiles in the 2nd floor shreader room across from Health Info Dir, 2nd floor Charting room, Pharmacy, Room 209, Room 203, Room 210.

Interview with Maintenance Director revealed the facility was not aware of the penetrations in the corridor walls and ceiling that would allow the transfer of smoke from one room to another.

Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants. The deficient practice had the potential to affect 5 of 8 residents.


Findings:

During the facility tour on 10/16/2015 observation revealed doors at following locations failed to latch in the frame: 3rd floor dietary kitchen, Room 221, 2nd floor storage #2 by elevator, 1st floor housekeeping, 1st floor sterilize room, chapel, x-ray, x-ray office and lab door.

Interview with Maintenance Director revealed the facility was not aware that these doors were required to latch in the frame.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 3 of 8 patients.

Findings:

During the facility tour on 10/16/2015 observation revealed doors for rooms converted to combustible storage room over 50 sq ft were not self-closing: Room 207, Room 213, Room 215, Room 221 and 3rd floor dump water room.


Interview with Maintenance Director revealed the facility was not aware that the rooms had been converted to storage roomsrequiring to self-close and latch in the frame.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. This deficiency has the potential to affect 8 of 8 residents.

Findings:

During the facility tour on 10/16/2015 observation revealed no sprinkler coverage in room 201 and 2nd floor corridor outside controller office.

Interview with Maintenance Director revealed the facility was not aware the automatic sprinkler system was not complete.

Based on visual observation, the facility failed to provide doors in accordance with NFPA 101:7.2.1. Multiple door releasing hardware creates a high risk of injury and/or death in delaying egress. The deficiency has the potential to affect staff of this facility.

Findings:

During the facility tour on 10/16/2015 observation revealed doors on the 2nd floor were equipped with more than one releasing mechanism.

Interview with Maintenance director revealed the facility was not aware that this was an issue.