HospitalInspections.org

Based on observation and interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly in their frames. This facility has 25 certified beds and at the time of the survey the census was 4.

Findings include:

Observation and interview on 9/16/14 , revealed the corridor door to Patient Room 303 did not latch properly when tested. Maintenance Staff A verified this observation.

Based on record review and staff interview, the facility is not conducting fire drills at vary times on each shift as required. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 patients and a census of 4.

Findings include:

Record review and staff interview on 9/16/14, revealed the facility failed to vary the times of the fire drills on the 2nd and 3rd shifts. Three of the four drills on the 2nd shift were conducted within the same 30 minutes and three of the four fire drills on the 3rd shift were conducted within the same 45 minute time frame. Maintenance Staff A verified these observations.

Based on record review, interview, and observation, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments and all occupants could be affected by this deficient practice. This facility has 25 licensed beds and at the time of the survey the census was 4.

Findings include:

During record review, interview and observation of the facility's fire safety components on 9/16/14, revealed the absence of documentation to indicate that quarterly inspections of the sprinkler system had been performed every three months. The quarterly inspections were dated as follows for the last 12 months: 6/18/14, 2/28/14, 12/20/13, and 7/23/13. Maintenance Staff A verified these findings.

Based on observations and interview the facility failed to provide window coverings that are flame retardant. This facility has 25 certified beds and at the time of the survey the census was 4.

Findings include:

1. Observation and interview on 9/16/14, revealed plastic mini-blinds located in Hood Room 310 and were not tagged as being flame retardant.
2. Observation and interview on 9/16/14, revealed fabric curtains located in the Nurse's Station Staff Lounge that were not tagged as being flame retardant.

Maintenance Staff A verified these observations.