HospitalInspections.org

Based on observation and record review, the facility failed to conduct fire drills at one per shift per quarter. This has the potential of affecting approximately all occupants in four of four smoke zones. This deficient practice has the potential to affect the readiness of the staff in the case of fire emergency. This facility has a capacity of 20 and census of 2 patients at the time of the survey.

Finding are:

On 5/2/2023 at 4:00 P.M., record review, the facility failed to conduct a fire drills for the second shifts in the first and third quarter and the first shifts for the first and third quarters of 2022.

During interview conducted on 5/2/2023 at 4:00 P.M., Maintenance personnel stated that they were unaware of the missing drills.

Based on record review and interview, the facility failed to conduct annual inspection and testing of all fire rated doors. This deficient practice has the potential to affect the operation and effectiveness of the rated doors throughout the facility, affecting approximately 8 occupants in four of four smoke zones. The facility has a capacity of 20 residents and a census of 2 patients at the time of the survey.

Finding are:
On 5/2/2023 at 2:30 P.M., record review indicated that the documentation for the annual fire door assembly inspection and testing could not be located.

During interview conducted on 5/2/2023 at 2:30 P.M., Maintenance personnel verified that they could not locate the documentation for the annual fire door assembly inspections.