HospitalInspections.org

Based on observation and interview, the facility failed to maintain 2 of 4 smoke barrier walls to resist the passage of smoke. Findings:

1. A tour of the facility was conducted on 10/15/24 and the following observations were made.

a) One unsealed penetration, associated with a computer wires was observed above the smoke doors next to the conference room.

b) One unsealed penetration, associated with a computer wires was observed above the smoke doors at the beginning of the Therapy hall.

2. The Plant manager was present when the smoke walls were observed on 10/15/24, and he acknowledged the unsealed penetrations to the smoke walls.

Based on record review and staff interview, the facility failed to assure the minimum required number of fire drills were conducted within the past year. Findings:

1. Review of the facility fire drill reports was conducted on 10/15/2024. There was no documentation the facility had conducted a fire drill for the following shift:

a. the second shift for the second quarter of 2024.

b. the first shift for the third quarter of 2024.

2. The Plant manager was interviewed on 10/15/2024 and stated the facility missed the fire drills for those two shifts.