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Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another. The deficient practice had the potential to affect 20 of 38 patients.

Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed that, when closed, the smoke barrier doors on the Geriatric Unit had a gap between them and could not prevent the passage of smoke.

Interview with maintenance personnel revealed the facility was not aware that an open space between the cross corridor doors was not acceptable.

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 20 of 38 patients.

Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed that the door to the following hazardous rooms were deficient:

Geriatric Unit
Oxygen Storage Room - no self-closing device installed
Clean Linen Closets - no self-closing device installed
Housekeeping Closet (by Room 33) - self-closing device is broken
Laundry - no self-closing device installed

Adult Unit
Food Storage - self-closing device is broken

Interview with the administrator and maintenance personnel revealed the facility was not aware that a self-closing device was required on doors to hazardous rooms.

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. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system which results in protection of life and property. This deficiency has the potential to affect 20 of 38 patients.

Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed that the clean linen closet on the Geriatric Unit did not have a sprinkler head installed for the protection of that area.

Interview with the administrator and maintenance personnel revealed the facility was not aware that the automatic sprinkler system was not complete.

Based on visual observation, the facility failed to remove electrical wiring and equipment in accordance with NFPA 70. When devices that are no longer in use remain it may result in a delay reaction during an emergency situation. The deficiency has the potential to affect of 20 of 38 patients.

Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed that three speical locking devices were installed at each exit door, none of which were currently in use and needed to be removed so it would not cause confusion for staff.

Interview with the administrator and maintenance personnel revealed the facility was not aware that the special locking devices were to be removed if not in use.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another. The deficient practice had the potential to affect 20 of 38 patients.

Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed that, when closed, the smoke barrier doors on the Geriatric Unit had a gap between them and could not prevent the passage of smoke.

Interview with maintenance personnel revealed the facility was not aware that an open space between the cross corridor doors was not acceptable.

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 20 of 38 patients.

Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed that the door to the following hazardous rooms were deficient:

Geriatric Unit
Oxygen Storage Room - no self-closing device installed
Clean Linen Closets - no self-closing device installed
Housekeeping Closet (by Room 33) - self-closing device is broken
Laundry - no self-closing device installed

Adult Unit
Food Storage - self-closing device is broken

Interview with the administrator and maintenance personnel revealed the facility was not aware that a self-closing device was required on doors to hazardous rooms.

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. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system which results in protection of life and property. This deficiency has the potential to affect 20 of 38 patients.

Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed that the clean linen closet on the Geriatric Unit did not have a sprinkler head installed for the protection of that area.

Interview with the administrator and maintenance personnel revealed the facility was not aware that the automatic sprinkler system was not complete.

Based on visual observation, the facility failed to remove electrical wiring and equipment in accordance with NFPA 70. When devices that are no longer in use remain it may result in a delay reaction during an emergency situation. The deficiency has the potential to affect of 20 of 38 patients.

Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed that three speical locking devices were installed at each exit door, none of which were currently in use and needed to be removed so it would not cause confusion for staff.

Interview with the administrator and maintenance personnel revealed the facility was not aware that the special locking devices were to be removed if not in use.