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Based on observation and staff interview, the facility failed to maintain exit corridors free of obstructions that projected from the wall into the corridor in 2 of 3 smoke compartments. This condition would slow the evacuation of patients served by these exits during an emergency, which had the potential to affect approximately 12 occupants. The facility census was 3.

Findings are:

1. Observation on 12-11-19 at 1:00 P.M., in the patient wing across from the nurse's station there was a Christmas tree that encroached into the required corridor width.
2. Observation on 12-11-19 at 1:45 P.M., in the ER Corridor there was a Christmas tree that encroached into the required corridor width.

Interview on 12-11-19 at 2:00 P.M., with maintenance staff advised that the facility was lead to believe it was okay to place the Christmas trees in those locations.

NFPA Standard:
NFPA 1-10.14.4 Vegetation and Christmas trees shall not obstruct corridors, exit ways, or other means of egress.

Based on observation and interview, the facility failed to assure the kitchen exhaust hood fire-extinguishing system was maintained and working properly. This deficient practice would affect how the system operated during a fire, and could fail to extinguish a cooking fire, which would affect approximately 16 patients and staff members 1 of 3 smoke compartments. The facility has the capacity for 12 beds with a census of 3 on the day of survey.

Findings are:
Record Review on 12-11-19 at 2:32 P.M., revealed the exhaust fan was not hooked up to the fire-extinguishing system and would not operate properly upon activation of the fire-extinguishing system.

During an interview on 12-11-19 at 2:32 P.m., Maintenance Staff A confirmed the exhaust fan was not hooked into the fire-extinguishing system.

Based on observation and record review, the facility failed to inspect, test and maintain the fire sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. This deficient practice has the potential to affect operation of the fire sprinkler system in the event of a fire, with the potential to affect all occupants in three of three smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings are:

Record review on 12/11/19 at 3:00 P.M., revealed the last quarterly inspections of the fire sprinkler system were conducted on 11/2018, 02/2019, and 08/28/2019. There was no documentation to review after 08-28-19.

Interview on 12/11/19 at 3:00 P.M., maintenance Staff acknowledged and confirmed findings of documentation review.

Based on observation and interview, the facility is not ensuring that doors to egress corridors are provided with a means suitable for keeping the doors closed. This deficient practice would not prevent the spread of fire and smoke affecting approximately 10 occupants in one of three smoke zones. This facility has a capacity of 12 and a census of 3 patients at the time of the survey.

Findings are:
Observation on 12/11/19 at 1:15 P.M., revealed the doors to the Communication room and the Sterilizer room when closed would not latch properly.

During an Interview on 12/11/19 at 1:15 P.M., maintenance staff A confirmed the Communication room and Sterilizer room doors would not latch.