HospitalInspections.org

Note K223.
Based on observation and interview the facility failed to provide a self-closing device on the door leading into the Physical Therapy area from the corridor. This deficient practice would allow for fire and smoke to travel beyond the Physical Therapy area into the corridor, and would affect all patients located in the facility. At the time of the inspection their were 4 patients in the facility. Facility is licensed for 25 patients.


Findings are:
Based on observation on 08-20-20 at 10::50 AM. the facility failed to provide a self closing device on the corridor door leading to the Physical Therapy area.

In an interview on 08-20-20 at 12:00 PM, Maintenance Personnel 1 confirmed the lack of a door closure for the Physical Therapy area.

Note K321
Based on observation and interview the facility failed to separate hazardous areas from the remainder of the building. This deficient practice would allow for fire and smoke to travel beyond this area into the HVAC area and would affect the staff located within the basement area, as well as patients located on the main level of the building. There were 4 patients in the facility at the time of the LSC survey. Facility is licensed for 25 patients.

Findings are;
Observation and interview on 08-20-20 at 12:00 PM revealed the door leading into the elevator machine room from the basement HVAC room failed to close and latch properly.

In an interview on 08-20-20 at 12:00 PM Maintenance Personnel 1 confirmed the findings.

Note K374
Based on observation and interview the facility failed to maintain doors in a smoke barrier. This deficient practice would allow for smoke and fire to travel beyond the the smoke compartment into adjacent areas. This would affect all patients within the facility as the Dining Room is located within the adjacent smoke compartment. There were four patients within the facility at the time of the LSC survey. Facility is licensed for 25 patients.

Findings are:
1. Observation and interview on 08-20-20 at 11:20 AM, revealed the fire rated doors located in the basement corridor adjacent to the central storage area failed to close and latch properly when tested.

2. Observation and interview on 08-20-20 at 11:30 AM revealed an excessive gap in a pair of doors leading to the Medical Clinic, and the West Corridor. It was possible to see into the adjacent space when the doors were closed.

An interview on 08-20-20 at 12:00 PM with Maintenance Personnel 1 confirmed the findings.