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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 25 of 25 residents.
1 of 3 corridors had doors that were deficient.

Findings:

During the facility tour, between the hours of 7:30am and 12:00pm it was observed that the patient room doors to room number 103 and 111 were not properly closing and latching in the door frame.

Interview with maintenance supervisor revealed the facility was not aware of the door to Rooms 103 and 111 were not latching in the frame.

Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 25 of 25 residents.

Findings:

During the record review, between the hours of 7:30am and 12:00pm it was obseved that the kitchen hood suppression system was due a semi-annual inspection.

Interview with maintenance supervisor revealed the facility was not aware the semi-annual inspection was not conducted on the hoop suppression system.