HospitalInspections.org

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of eight smoke compartments. This facility has a capacity of 25 and a census of 15 patients.

Findings include:

Observation of the Mechanical Room located in the Basement on 7/27/22 at 11:40 a.m., revealed an open conduit penetration with data wires located above the door.
Maintenance Staff confirmed these observations during the survey process.

Based on record review and interview, the facility failed to hold fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1.6/19.7.1.6. This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility had a capacity of 25 and a census of 15 residents at the time of the survey.

Findings include:

Record review on 7/27/22, at 10:41a.m., of the facility fire drill documentation revealed a third shift drill was not available for first quarter in 2022. The first and second shift drills are also held within the same hours for first and second quarters in 2022 and third and fourth quarters in 2021.

Results of the record review were acknowledged by Maintenance Staff at the time of exit.