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Based on visual observation this non-sprinklered facility failed to assure that the smoke compartmental of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. Ceiling that are part of smoke fire rating shall be in place .
Finding: During the facility tour , on 10/28-29/2014 observation revealed unsealed corridor penetration at these locations.
1) Corridor wall into psych. break room unsealed wires.
2)2nd floor Patient hall by room 114 unsealed water pipe
3) 2nd floor Patient hall by room 106 unsealed water pipe
4) Need to remove non-rated caulk by CNO office and replace with rated marterial
5) Unsealed gray and white wire in EKG room
6) unsealed green wires by House Keeping Office

Based on visual observation the facility failed to provide corridor doors that were 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 2 of 2 residents. Finding: During the facility tour, on 10/28-29/2014 observation revealed not latching or smoke resistive at these locations.
1) Men's restroom across from pharmacy 2nd floor door not latching
2) Door into pharmacy is a Dutch door and not smoke resistive
3) Corridor to IT room is a Dutch door and not smoke resistive
4) Janitors storage room door have been removed
5) Door not smoke resistive to neular medicine.

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 2 of 2 patients.

During the facility tour on 10/28-29/ 2014 observation revealed barrier doors by x-ray not closing in their frame.

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 compartments have hazardous areas that are not separated. Finding: During the facility tour, on 10/28-29/2014 observation revealed Padded room storage room have no door self-closing device. 2) Respiratory storage room door have no self-closing device, 3) Neular medicine room storage door have no self-closing device.

Based on observation the facility failed to provide smoke detection system that protect all rooms and corridors. Corridors and rooms open to the corridor should smoke detection. The deficient practice had the potential to affect 2 of 2 patients. The residents that mostly used this area are the four smokers. Finding: During the facility tour, on 10/28-29/2014 observation revealed no smoke protection in ICU area behind nurse's station.

Based on visual observation, the facility failed to assure that all smoking areas were supplied with a metal, self-closing container. cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion.
Finding:
During the facility tour on 10/28-29/2014 observation revealed ashtrays or not metal containers with self-closing covers in the Intensive Outpatient smoking area.

Based on visual observation the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system.
Finding:
During the facility tour on 10/28-29/2014 record review revealed hood suppression system last inspection was 4/7/2014 this exceed the six month limit.

Based on observation this facility failed to assure electrical wiring and electrical panels were secure in a safety manor, that will allow operating and maintenance without danger to technical personal or staff and patients.
During facility tour on 10/28-29/2014 observation revealed extensions cords being for permanent wiring for air-conditioners in these areas, 1) Chief Nurse's Office, 2) Pharmacy area, 3) Patient Action Room, 4) Case Management Office.

Based on visual observation this non-sprinklered facility failed to assure that the smoke compartmental of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. Ceiling that are part of smoke fire rating shall be in place .
Finding: During the facility tour , on 10/28-29/2014 observation revealed unsealed corridor penetration at these locations.
1) Corridor wall into psych. break room unsealed wires.
2)2nd floor Patient hall by room 114 unsealed water pipe
3) 2nd floor Patient hall by room 106 unsealed water pipe
4) Need to remove non-rated caulk by CNO office and replace with rated marterial
5) Unsealed gray and white wire in EKG room
6) unsealed green wires by House Keeping Office

Based on visual observation the facility failed to provide corridor doors that were 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 2 of 2 residents. Finding: During the facility tour, on 10/28-29/2014 observation revealed not latching or smoke resistive at these locations.
1) Men's restroom across from pharmacy 2nd floor door not latching
2) Door into pharmacy is a Dutch door and not smoke resistive
3) Corridor to IT room is a Dutch door and not smoke resistive
4) Janitors storage room door have been removed
5) Door not smoke resistive to neular medicine.

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 2 of 2 patients.

During the facility tour on 10/28-29/ 2014 observation revealed barrier doors by x-ray not closing in their frame.

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 compartments have hazardous areas that are not separated. Finding: During the facility tour, on 10/28-29/2014 observation revealed Padded room storage room have no door self-closing device. 2) Respiratory storage room door have no self-closing device, 3) Neular medicine room storage door have no self-closing device.

Based on observation the facility failed to provide smoke detection system that protect all rooms and corridors. Corridors and rooms open to the corridor should smoke detection. The deficient practice had the potential to affect 2 of 2 patients. The residents that mostly used this area are the four smokers. Finding: During the facility tour, on 10/28-29/2014 observation revealed no smoke protection in ICU area behind nurse's station.

Based on visual observation, the facility failed to assure that all smoking areas were supplied with a metal, self-closing container. cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion.
Finding:
During the facility tour on 10/28-29/2014 observation revealed ashtrays or not metal containers with self-closing covers in the Intensive Outpatient smoking area.

Based on visual observation the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system.
Finding:
During the facility tour on 10/28-29/2014 record review revealed hood suppression system last inspection was 4/7/2014 this exceed the six month limit.

Based on observation this facility failed to assure electrical wiring and electrical panels were secure in a safety manor, that will allow operating and maintenance without danger to technical personal or staff and patients.
During facility tour on 10/28-29/2014 observation revealed extensions cords being for permanent wiring for air-conditioners in these areas, 1) Chief Nurse's Office, 2) Pharmacy area, 3) Patient Action Room, 4) Case Management Office.