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Based on observation and staff interviews, the facility failed to provide the gas range in the kitchen with a means for automatic ignition. If this burner, on the gas range was to be accidentally bumped on without the automatic ignition, it could fill the smoke compartment with unburned gas with a potential of an explosion or fire. This deficient practice affects the occupants that use the dining room and approximately 20 occupants in that smoke zone. This facility has a capacity of 20 and a census of 6 at the time of the survey.

Findings are:
Observation on 01/16/19 at 11:45 A.M., revealed that middle back burner of the six burners on the range in the kitchen, when turned to the on position, would not automatically ignite.

2) During an interview on 01/16/19 at 11:45 A.M., with maintenance staff A confirmed this observation.

Based on observation and staff interviews, the facility did not ensure that corridor separation doors would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke between 2 of 6 smoke zones and affected approximately 15 occupants. This facility has a capacity of 20 beds and a census of 6 patients at the time of the survey.

Findings are:
Observation on 01/16/19 at 1:15 P.M., revealed the smoke separation doors between the emergency rooms and surgery when closed had a substantial gap which would not prevent the spread of fire and smoke.

Interview on 01/16/19 at 1:15 P.M., with Maintenance Staff confirmed the gap between the doors.

Based on interview and documentation review, the facility failed to implement an annual testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility. These deficient practices failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke and affected all occupants in all smoke compartments. The facility capacity was 20, with a census of 6 on the day of survey.
Findings are:

Documentation review on 01-16-19 at 2:00 P.M. revealed that the facility failed to provide written documentation of annual inspections and testing of the all fire rated doors throughout the facility.

During an interview on 01-16-19 at 2:00 P.M., Maintenance Staff A confirmed the lack of complete annual fire rated door inspections.