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 and could affect approximately 18 residents as well as staff. This facility has a capacity of 25 and a census of 11 residents.

Findings include:

1. Observation of the Emergency Power Electrical Room on 6/13/19 at 10:36 a.m., revealed an 1/2 inch penetration surrounding a two inch pipe located in the ceiling.

2. Observation of the Main Power room on 6/13/19 at 10:36 a.m., revealed an 1/2 inch penetration surrounding a three inch pipe located in the ceiling.

Maintenance Staff confirmed these observations during the survey process.

Based on interview and record review, the facility failed to maintain the range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 11.2.1 by having documentation supporting the system is connected to the Fire Alarm System. This deficient practice affected one of four smoke zones in the building, including the main dining room. This facility had a capacity of 25 and a census of 10 residents at the time of the survey.

Findings include:

Record review on 6/18/19 at 11:38 a.m., revealed the documentation for the commercial cooking suppression system and fire alarm system did not show the system was connected to the fire alarm system as required by code.

This deficient practice was confirmed by Maintenance Staff at the time of exit.

Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. The documentation did not show the drills have been held as required. 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 11 residents at the time of the survey.

Findings include:

Record review on 6/13/19 at 12:09 p.m., of the facility fire drill documentation conducted during 2018 revealed the second quarter was missing a first shift drill.

Maintenance Staff and Administrative Staff verified this observation during the survey process.