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Based on observation and staff interview it was determined the facility failed to provide hazardous areas with smoke tight construction.

This could place all 16 residents and staff at risk in the event of a fire in the building.

The findings include:

During a tour of the facility with Staff M on 02/05/2019 between 08:15am and 11:30am observation revealed unsealed penetrations of the first floor elevator machine room and the 3rd floor north electrical room.

These findings were confirmed by Staff M at the time of discovery.

2012 NFPA 101, Chapter 19, Sections 19.3.2.1 and 19.3.2.1.5 and Chapter 8, Sectons 8.7.1.1 and 8.3.5

Based on observation and staff interview it was determined the commercial cooking hood located in the facility kitchen was not properly constructed to meet the requirements of NFPA 96.

This could place the kitchen staff at risk in the event of a kitchen fire.

The findings were:

During a tour of the facility with Staff M on 02/05/2019 between 08:15am and 11:30am observation revealed the commercial hood did not have at least a 6" overhang on the exposed side of the deep fryer.

This finding was confirmed by Staff M at the time of discovery.

2012 NFPA 101, 19.3.2.5.1, 9.2.3, 2011 NFPA 96, 10.3.1, 12.1

Based on observation and staff interview it was determined the facility failed to provide fire and smoke barrier walls with at least a one half hour fire resistance rating.

This could place all 16 residents and staff at risk in the event of a fire in the facility.

The findings were:

During a tour of the facility with Staff M on 02/05/2019 between 08:15 am and 11:30am observation revealed the fire and smoke barrier wall located across the corridor from the elevators had improperly constructed and sealed patches in the wall.

It was also observed the second floor fire and smoke barrier wall across from room #217 had a 8' section of the fire and smoke barrier wall not sealed to the deck with an approved fire stop material.

Observation further revealed the fire and smoke barrier wall at medical imaging had penetrations not sealed with approved fire stop material.

These findings were confirmed by Staff M at the time of discovery.

2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, Chapter 4, Section 4.6.12.1

2012 NFPA 101, Chapter 19, Section 19.3.7.3, Chapter 8, Section 8.5.2.1

2012 NFPA 101, Chapter 19, Section 19.1.1.1.3, Chapter 4, Sections 4.2.3, 4.6.12.1

Based on observation and staff interview it was determined the facility was using unapproved heating devices in nonpatient areas.

This finding could put 11 staff at risk in the event of a fire in the facility.

The findings were:

Duringa tour of the facility with Staff M on 02/05/2019 between 08:15am and 11:30am observation revealed portable space heaters with heating elements exceeding 212 degrees farhenheit being used in 3 offices in the administrative wing, the second floor nurse's station office, the third floor pharmacy, and the third floor social services office.

These findings were confirmed by Staff M at the time of discovery.

2012 NFPA 101 Chapter 19, Section 19.7.8