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324 MILLER MOUNTAIN DRIVE

WEBSTER SPRINGS, WV 26288

Fire Alarm System - Testing and Maintenance

Tag No.: K0345

Based on observation and staff interview it was determined the facility failed to ensure the fire alarm system was maintained in accordance with NFPA (National Fire Protection Association) 72. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 2.

Findings include:

On 04/05/22 at approximately 2:20 p.m., building tour revealed two (2) smoke detectors had been removed from the old billing office room that is now being used for storage on the second floor.

On 04/05/22 at approximately 2:20 p.m., building tour revealed the smoke detector had been removed from Room 222.

On 04/06/22 at approximately 11:20 a.m., the above findings were discussed with the Maintenance Supervisor and Administrator upon exit.

Corridor - Doors

Tag No.: K0363

Based on document review and staff interview it was determined the facility failed to maintain corridor doors in accordance with NFPA (National Fire Protection Association) 80. Facility Census 2.

Findings include:

On 4/05/22 at approximately 1:45 p.m., building tour revealed the door to the old billing manager's office, now used for storage, had four (4) 3/8 inch holes where closure had been removed.

On 4/05/22 at approximately 1:48 p.m., building tour revealed the door to Room 236 had holes where hardware had been removed.

On 4/06/22 at approximately 10:20 p.m., the above findings were discussed with the Maintenance Supervisor and Administrator on exit.

Subdivision of Building Spaces - Smoke Barrie

Tag No.: K0374

Based on document review and staff interview it was determined the facility failed to maintain fire doors in accordance with NFPA (National Fire Protection Association) 80. Facility Census 2.

Findings include:

On 4/05/22 at approximately 2:45 p.m., building tour of the outpatient Physical Therapy clinic, located in Cowen, West Virginia, revealed the three (3) hour fire door was propped open with a wedge.

On 4/05/22 at approximately 2:50 p.m., building tour of the outpatient Physical Therapy clinic, located in Cowen, West Virginia, revealed the two (2) hour fire door was propped open with a wedge and had a latch removed from door knob.

On 4/06/22 at approximately 10:20 p.m., the above findings were discussed with Maintenance Supervisor and with Administrator on exit.