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Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 34 of 34 residents.

Findings:

During the facility tour on 11/21/2019, between the hours of 8:00a-3:30p observation revealed the sprinkler system was not installed correctly in in the area by the vending machines and the hall by therapy.

Interview with Director of Plant Operations revealed the facility was not aware the automatic sprinkler system was not complete.

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. The deficient practice had the potential to affect 34 of 34 residents.


Findings:

During the facility tour on 11/21/2019, between the hours of 8:00a-3:30p observation revealed doors located throughout the facility did not close and latch properly in the frame.

Interview with Director of Plant Operation revealed the facility was not aware of the doors located throughout the facility did not close and latch properly in the frame.