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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 8 of 8 residents.
4 of 4 corridors had doors that were deficient.

Findings:

During the facility tour on 1/11/2016 observation revealed dining hall door did not latch into the frame.

Interview with Maintenance revealed the facility was not aware of the door to dining hall did not latching in the frame.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 8 of 8 residents.
4 of 4 smoke barriers were deficient.

Findings:

During the facility tour on 1/11/2016 observation revealed penetration in the barrier wall by lab, nurses station, middle hall and back hall by isolation room.

Interview with Maintenance revealed the facility was not aware of unsealed penetration.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 8 of 8 residents.


Findings:

During the record review on 1/11/2016 it was observed that fire drills were not being conduted 1 per shift per quarter. Record review revealed no fire drill for 2nd, 3rd & 4th quarter of the night shift and 4th quarter of the day shift.

Interview with Maintenance revealed the facility was aware fire drills were not being held.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect of residents.

Findings:

During the facility tour on 1/11/2016 observation revealed open junction boxes located in the maintenance room and above ceiling at the barrier walls.

Interview with maintenance revealed the facility was not aware of the open junction boxes in these areas.

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 8 of 8 residents.
4 of 4 corridors had doors that were deficient.

Findings:

During the facility tour on 1/11/2016 observation revealed dining hall door did not latch into the frame.

Interview with Maintenance revealed the facility was not aware of the door to dining hall did not latching in the frame.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 8 of 8 residents.
4 of 4 smoke barriers were deficient.

Findings:

During the facility tour on 1/11/2016 observation revealed penetration in the barrier wall by lab, nurses station, middle hall and back hall by isolation room.

Interview with Maintenance revealed the facility was not aware of unsealed penetration.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 8 of 8 residents.


Findings:

During the record review on 1/11/2016 it was observed that fire drills were not being conduted 1 per shift per quarter. Record review revealed no fire drill for 2nd, 3rd & 4th quarter of the night shift and 4th quarter of the day shift.

Interview with Maintenance revealed the facility was aware fire drills were not being held.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect of residents.

Findings:

During the facility tour on 1/11/2016 observation revealed open junction boxes located in the maintenance room and above ceiling at the barrier walls.

Interview with maintenance revealed the facility was not aware of the open junction boxes in these areas.