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Based on visual observation the facility failed to provide the continuation of the exit discharge to include access to the public way from all required exits. The access provides an easier transition for occupants to evacuate from all exits in the building. The deficient practice had the potential to affect 4 of 4 residents.
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Findings:

During the facility tour on 3/23/2018, between the hours of 9:00a-5:30p observation revealed the exit discharge from the stairwell by elevator 2 did not lead to the public way.

Interview with Administrator revealed the facility was not aware that the exit discharge did not continue to the public way.

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. The deficient practice had the potential to affect 4 of 4 residents.


Findings:

During the facility tour on 3/23/2018, between the hours of 9:00a-5:30p observation revealed door to EVS supply / clean linen and door to kitchen storage were not self closing.

Interview with Administrator revealed the facility was not aware that the doors to the hazardous areas were required to self-close.

Based on visual observation this non 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 4 of 4 residents.

Findings:

During the facility tour on 3/23/2018, between the hours of 9:00a-5:30p observation revealed penetrations in the corridor walls above ceiling at station 1 and past barrier to 300/400 hall.

Interview with Administrator revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Based on visual observation the facility failed to provide corridor doors that were not 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 4 of 4 residents.

Findings:

During the facility tour on 3/23/2018, between the hours of 9:00a-5:30p observation revealed the doors to processing, pharmacy, pharmacy asst., kitchen, 1st floor break room and dining room did not latch in the frame.

Interview with Administrator revealed the facility was not aware of the door to these rooms was not latching in the frame.

Based on visual observation, the facility failed to provide a remote annunciator to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 4 of 4 residents.

Findings:

During the facility tour on 3/23/2018, between the hours of 9:00a-5:30p observation revealed no generator annunciator located readily observed by personnel.

Interview with Administrator revealed the facility was not aware that a remote annunciator was not installed in the proper location to indicate alarm conditions of the emergency generator.

Based on visual observation and record review, the facility failed to assure that the monthly testing program on the emergency generator was conducted and documented. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 4 of 4 residents.
12 of 12 months were deficient.

Findings:

During the facility tour and record review on 3/23/2018, between the hours of 9:00a-5:30p record review revealed no testing under load was being conducted or documented. It was also observed that no emergency stop was located remote of the generator and that there was no battery charger connected to the battery of the generator.

Interview with Administrator revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator. He also was not aware that a remote stop remote of the generator and a battery charger was required.