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Based on observation and interview, the facility failed to ensure that fire rated stair enclosures would resist the passage of fire and smoke from one floor to another. This deficient practice would not prevent the spread of fire and smoke from entering the exit enclosure and compromising egress from the basement level affecting all occupants in 2 smoke compartments (basement and main floor assisted living wing). The facility has the capacity for 24 beds with a census of 18 on the day of survey.

Findings are:
Observation and staff interview on 12-18-2019 at 10:35 AM revealed the following:

Main floor east exit stair door from the Assisted Living wing failed to securely latch into the frame when closed under its own power.

During an interview on 12-18-2019 at 10:35 AM, Maintenance Staff A confirmed the door failed to latch.

Based on observation and staff interview, the facility failed to ensure that all areas of the building were fire sprinkler protected. This deficient practice would allow fire, smoke and gases in the unprotected spaces to spread and over power the fire sprinkler system,, affecting approximately 6 occupants in 1 smoke compartment. Facility census was 18 and licensed for 24 at the time of the survey.

Finding are:
Observation and staff interview on 12-18-2019 at 11:45 AM revealed the following:

No fire sprinkler protection was provided in the main floor Outpatient Recovery Center corridor.

During interview on 12-18-2019 at 11:45 AM, Maintenance Staff A confirmed no sprinkler protection was provided and stated that recovery room glass partitions were recently installed.