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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 7 of 7 residents.


Findings:

During the facility tour on 1/22/2019, between the hours of 9:30a-4:30p observation revealed the doors to rooms 112, 108, 110 and room across from Medical Director's office were not self-closing. These rooms were greater than 50 square feet being used as storage.


Interview with Administration revealed the facility was not aware that the doors to the hazardous areas were required to self-close and latch in the frame.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect staff and patients.

Findings:

During the facility tour and the record review on 1/22/2019, between the hours of 9:00a-4:30p observation and record review revealed the fire alarm had not been serviced and tested as required.

Interview with Administration revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system.

Based on visual observation the facility failed to assure that the areas open to the corridor were protected in a manner allowed by code. Providing approved protection of the corridor is essential in protecting the corridor in case of a fire or other smoke emergency. The deficient practice had the potential to affect 7 of 7 residents.


Findings:

During the facility tour on 1/22/2019, between the hours of 9:30a-4:30p observation revealed the front foyer and waiting area in the clinic were open to the corridor and not protected consistant with other corridors.

Interview with Administration revealed the facility was not aware of the area open to the corridor would allow the transfer of smoke to the corridor and were not properly protected.