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Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation 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. The deficient practice had the potential to affect 27 of 27 residents.
3 of 3 smoke compartments were deficient.

Findings:

During the facility tour on 5/28/2015 observation revealed penetrations in the barrier wall in the administration corridor, 50+ area and Adult side.

Interview with Maintenance director revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke or fire.

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.


Findings:

During the facility tour on 5/29/2015 to 6/1/2015 observation revealed:
1) Door to kitchen did not latch into frame.
2) Door to lab blocked open, would not close and latch.

Interview with Maintenance Director revealed the facility was aware of the door to Lab not closing and latching due Air Condition issues, in the process of getting A/C problem corrected.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 27 of 27 residents.
1 of 3 corridors has emergency lighting that is deficient.

Findings:

During the facility tour on 5/28/2015 observation revealed emergency lights located in Group 2, Group 4 & IOP entrance did not function when tested.

Interview with Maintenance Director revealed the facility was not aware that these emergency lightings were compromised.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency.

Findings:

During the facility tour and the record review on 5/28/2015 observation and record review revealed no annual inspection had been performed on the fire alarm system.

Interview with Maintenance Director revealed the facility was not aware that the inspection was required on the fire alarm system.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 13 of 188 residents.

Findings:

During the facility tour and the record review on 5/29/2015 to 6/1/2015 observation and record review revealed:
1) Fire alarm system yellow tagged due to 4 AHU not shutting down when system activated.
2) Clean agent systems on 1st and 4th floors yellow tagged due to pressure test needed.

Interview with Maintenance Director revealed the facility was aware that the systems were yellow tagged and are in the process of have the fire alarm system issues corrected.

Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions, in the egress corridor, hinder occupant egress in emergency situations. This deficient practice could potentially affect 42 of 188 residents in the facility.

Findings:

During the facility tour on 5/29/2015 to 6/1/2015 observation revealed storage of beds in corridor on 4th floor by room 467 and the end of hall and 2nd floor ICU.

Interview with Maintenance Director revealed the facility was not aware that the exits in the corridors were obstructed.

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation 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. The deficient practice had the potential to affect 27 of 27 residents.
3 of 3 smoke compartments were deficient.

Findings:

During the facility tour on 5/28/2015 observation revealed penetrations in the barrier wall in the administration corridor, 50+ area and Adult side.

Interview with Maintenance director revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke or fire.

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.


Findings:

During the facility tour on 5/29/2015 to 6/1/2015 observation revealed:
1) Door to kitchen did not latch into frame.
2) Door to lab blocked open, would not close and latch.

Interview with Maintenance Director revealed the facility was aware of the door to Lab not closing and latching due Air Condition issues, in the process of getting A/C problem corrected.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 27 of 27 residents.
1 of 3 corridors has emergency lighting that is deficient.

Findings:

During the facility tour on 5/28/2015 observation revealed emergency lights located in Group 2, Group 4 & IOP entrance did not function when tested.

Interview with Maintenance Director revealed the facility was not aware that these emergency lightings were compromised.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency.

Findings:

During the facility tour and the record review on 5/28/2015 observation and record review revealed no annual inspection had been performed on the fire alarm system.

Interview with Maintenance Director revealed the facility was not aware that the inspection was required on the fire alarm system.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 13 of 188 residents.

Findings:

During the facility tour and the record review on 5/29/2015 to 6/1/2015 observation and record review revealed:
1) Fire alarm system yellow tagged due to 4 AHU not shutting down when system activated.
2) Clean agent systems on 1st and 4th floors yellow tagged due to pressure test needed.

Interview with Maintenance Director revealed the facility was aware that the systems were yellow tagged and are in the process of have the fire alarm system issues corrected.

Based on visual observation, the facility failed to assure that the means of egress was free of obstructions or impediments to full instant use of the exit passage way. Obstructions, in the egress corridor, hinder occupant egress in emergency situations. This deficient practice could potentially affect 42 of 188 residents in the facility.

Findings:

During the facility tour on 5/29/2015 to 6/1/2015 observation revealed storage of beds in corridor on 4th floor by room 467 and the end of hall and 2nd floor ICU.

Interview with Maintenance Director revealed the facility was not aware that the exits in the corridors were obstructed.