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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 4 of 4 residents.
2 of 3 smoke compartments were deficient.

Findings:

During the facility tour on 7/19/2017, between the hours of 10:00a-3:30p observation revealed penetrations located in the wall where fold down nurses desk were installed.

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

Based on visual observation the facility failed to provide that the gas and vacuum piped system was maintained through a documented maintenance program in accordance with the requirements of NFPA 99. That an inspection and maintenance schedule be established through risk assessment considering manufacturer recommendations. Activation of the system will provide needed oxygen to patients, which results in protection of life. This deficiency has the potential to affect 4 of 4 residents.

Findings:

During the facility tour on 7/19/2017, between the hours of 10:00a-3:30p observation revealed no documentated maintenance program with inspection and maintenance schedule was provided.

Interview with administration revealed the facility was not aware that the maintenance program had not been established and maintained on the gas and vacuum piped system.

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 4 of 4 residents.

Findings:

During the facility tour on 7/19/2017, between the hours of 10:00a-3:30p observation revealed no record of inspection and testing are conducted or maintained as required.

Interview with administration 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 4 of 4 residents.

Findings:

During the facility tour on 7/19/2017, between the hours of 10:00a-3:30p observation revealed emergency stop not located remote of the emergency generator.

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