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Based on observation and interview, the facility failed to ensure 4 of more than 10 storage room doors serving hazardous areas closed and latched to prevent the passage of smoke. This deficient practice could affect residents, visitors and staff in and near the storage rooms.

Findings include:

Based on observations with the maintenance supervisor on 04/29/11 between 1:15 p.m. and 2:50 p.m., the door to the second floor soiled utility room containing soiled linens and cleaning supplies, patient room 212 being used as a storage room, the housekeeping closet containing cleaning supplies and chemicals and the basement cleaning supply room containing combustibles such as paper and boxes did not have a door closer and therefore did not automatically close and latch. The maintenance supervisor acknowledged the problem areas at the time of observation.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic dry sprinkler piping systems was inspected every five years as required by NFPA 25, the Standards for Water Based Fire Protection Systems 10-2.2. This deficient practice affects all residents, staff and visitors.

Findings include:

Based on record review with the maintenance supervisor on 04/28/11 at 2:50 p.m., the sprinkler system reports supplied by McDaniel dated 02/11/11, 11/03/10, 08/12/10 and 05/18/10 provided no documentation to indicate an internal inspection of the sprinkler system had been completed in the past five years. The maintenance supervisor stated at the time of the record review, he thought the system had been checked but had no documentation and did not present evidence of an internal pipe inspection.

2. Based on observation and interview, the facility failed to replace 2 of 2 sprinklers in the kitchen which had been painted. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected, tested and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1998 edition, 2-2.1.1 requires any sprinkler shall be replaced which is painted, corroded, damaged, loaded, or in the improper orientation. This deficient practice could effect the staff in and near the kitchen.

Findings include:

Based on observation during a tour with the maintenance supervisor on 04/29/11 at 1:25 p.m., the two automatic sprinklers in the basement kitchen were painted. The maintenance supervisor stated at the time of the observation, he was not aware of the problem.