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Based upon observations made in the presence of the facility director on 01/08/2019, it was determined that the facility did not continuously maintain the means of egress and exits to the public way at all times in accordance with NFPA 101: 19.2.1, 7.1.10.1


Findings include:

During the facility tour the facilities corridor and the OR exit corridor were observed to be partially blocked by storage. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency in accordance with NFPA 101 7.1.10.1

Based upon observations made in the presence of the plant manager on 01/08/2019, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5

Findings include:

During the facility tour the dialysis storage room was observed to not have a self-closing device. The doors shall be self-closing or automatic-closing in accordance with NFPA 101 19.3.2.1.3.

During the facility tour it was observed that the door to the dirty laundry failed to self -close to the latch position as required in accordance with NFPA 101

Based upon record review made in the presence of the plant manager on 01/08/2019, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 9.6.1.3, 9.6.1.5.; and NFPA 72.

Findings include:

During the record review the facility failed to provide documentation that the fire alarm control panel batteries had been tested under load two times in the last year. Batteries need to be tested semiannually in accordance with NFPA 101 19.3.4.1.& 9.6.1.1.; and NFPA 72 Table 14.4.5

Based upon observations made during the record review with the facility director on 01/08/2019, it was determined that the facility did not provide a written fire safety plan in accordance with NFPA 101 19.7.2.2.

Findings include:

During the record review it was observed that the facility failed to provide a written documentation for the fire safety plan that included all nine objectives, evacuation of the smoke compartment and emergency phone call to fire department was not observed to be in the policy. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire.
In accordance with NFPA 19.7.2.2

Based upon record review made in the presence of the plant manager on 01/08/2019, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.4. through 19.7.1.7

Findings include:

During the record review the facility failed to provide documentation of 1 of the required 8 fire drills, the 1st quarter night shift was missing. The plant manager confirmed these findings. Fire drills shall be held at unexpected time under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.4 Through 19.7.1.7.

Based upon observations made in the presence of the plant manager on 01/08/2019, it was determined that the facility did not use power and extension cords in accordance with NFPA 101, 99 and 70

Findings include:

During the facility tour it was observed that a heat gun was plugged into a power strip in the physical therapy area. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 70 110-3b