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Based on visual observation the facility failed to assure that two hour fire rated construction enclosing the stairwell was not compromised. This reduces or eliminates the potential of fire and/or smoke spreading from one floor to another. This deficiency has the potential to affect 24 of 24 residents.

Findings:

During the facility tour, between the hours of 11:00am and 2:30pm, it was observed that the door to the stairwell by Room 373 was dragging on the floor and not closing in the frame.

Interview with maintenance staff revealed the facility was not aware that the fire rated construction of the stairwell was compromised.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect of residents.
3 of 4 quarters in 2012-2013 are deficient.

Findings:

During the record review, between the hours of 11:00am and 2:30pm, it was observed that documentation for the following drills could not be provided for review:

1st Quarter, 2013
6pm-6am shift

2nd Quarter, 2013
6am-6pm shift
6pm-6am shift

3rd Quarter, 2013
6pm-6am shift

Interview with the nursing staff revealed that they did not have the fire drill documentation and referred me to the facility environmental/maintenance department. Upon review of the drills provided by maintenance, documentation for the above shifts was not found.