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Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 soiled utility rooms was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect staff and up to 16 on the third floor.

Findings include:

Based on observations during a tour of the facility with the Maintenance Director and Vice President on 11/14/17 at 12:40 p.m., the soiled utility room, which contained over 64 gallons of soiled linen, was not equipped with a self-closing device. Based on interview at the time of observations, the Maintenance Director agreed the room contained soiled linen and the door was not equipped with a self-closer.

3.1-19(b)

Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system gauges and valves had been inspected for 12 of 12 past months. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal supply pressure is being maintained. NFPA 25, 13.3.2.1.1 states valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. This deficient practice could affect all residents, staff, and visitors in the facility.

Findings include:

Based on record review with the Maintenance Director and Vice President on 11/14/17 at 11:33 a.m., there was no monthly inspection of the wet sprinkler system's gauges and valves available for review. During an interview at the time of record review, the Maintenance Director stated no monthly checks of the sprinkler system's gauges or valves were recorded.

3.1-19(b)