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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 15 of 27 residents.
1 of 3 smoke compartments have hazardous areas that are not separated.

Findings:

During the facility tour on 3/24/2015 observation revealed that the door to the medical storage room would not self-close.


Interview with maintenance staff revealed the facility was not aware that the doors to the hazardous areas were required to self-close and latch in the frame.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 12 of 27 residents.
3 of 3 corridors has emergency lighting that is deficient.

Findings:

During the facility tour on 3/24/2015 observation revealed the emergency lights failed to function properly when tested.

Interview with maintenance staff revealed the facility was not aware that the emergency lighting in Main/Dorm A were compromised.

Based on visual observation the facility failed to provide exit lighting along the entire length of the exit access. Exit lights provide visual assurance of the direction of the exit door. The deficient practice had the potential to affect 12 of 27 residents.
6 of 7 exit lights are deficient.

Findings:

During the facility tour on 3/24/2015 observation revealed the exit lights did not function properly when tested.

Interview with maintenance staff revealed the facility was not aware that exit signage didn't work.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 12 of 27 residents.
4 of 4 quarters in 2014-2015 were deficient.

Findings:

During the record review on 3/24/2015 record review revealed fire drills on 10:30p to 6:30a shift were not completed.

Interview with maintenance staff revealed the facility was not aware fire drills were not being held for night shift and verified by the Administrator during the exit interview.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect all employees.

Findings:

During the facility tour and the record review on 3/24/2015 observation revealed fire alarm system had not been serviced as required.

Interview with facility manager revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system and was acknowledged by the Administrator.