HospitalInspections.org

Based on observations and interview, the facility failed to remain in compliance with standards established to ensure the operation of fire doors installed in the building to prevent the spread of fire, smoke and the toxic products of combustion.

Findings:

During the review of records on 4/19/23 between 7:50 a.m. and 9:00 a.m., records of the annual fire door inspection were reviewed. The door inspections were performed by a contractor in Novemeber of 2022. Based on the inspection report, the following fire doors have deficiencies that have not been corrected per the Assistant Maintenence Director. Doors identified in the report were: #10, 17, 27, 82, 87, 122, 123, 124, 131, 132, 134, 135, 136, and 146. Attached as a part of this report was an inspection report for each fire door that identifies the deficency. Photographic evidence was obtained.

The Assistant Maintenance Director was present when the deficiency was identified.

The findings were reconfirmed at the exit conference at 11:00 a.m. on 4/19/23 with the Assistant Maintenance Director. There was no Administrator on site to include in the exit conference.

NFPA 101 (2012 ed.) Ch 4.6.12
NFPA 80 (2010 ed.) Ch 4.9.3, 5.1.3.1, 5.1.4, 5.1.5.1, 5.2.1

Based on observation and interview, the facility failed to maintain the fire alarm system. Maintaining the fire alarm system ensures proper operation and lessens the chance of a delayed alarm activation under hazardous conditions.

Findings:

During record review on 4/19/23 between 7:50 a.m. and 9:00 a.m., the facility failed to provide evidence of the annual fire alarm inspection and testing. Maintenance staff provided the fire alarm binder but there were no records of inspections or testing in the binder. Photograhic evidence was obtained.

The Assistant Maintenance Director was present when the deficiency was identified.

The findings were reconfirmed at the exit conference at 11:00 a.m. on 4/19/23 with the Assistant Maintenance Director. There was no Administrator on site to include in the exit conference.

NFPA 101 (2012 ed.) 19.3.4.1, 9.6
NFPA 72 (2010 ed.) 14.3.1, 14.4.5

Based on record review and interview, the facility failed to conduct fire drills as required by NFPA 101. Fire drills are essential to the training of staff and residents in proper procedure in emergency situations. Untrained staff can allow confusion and possible delays in proper procedure in an emergency and jeopardize all within the facility.

Findings:

During record review on 4/19/23 between 7:50 a.m. and 9:00 a.m., a request to see the fire drill logs was made. A binder notebook labeled fire drills was provided but there were no records of any fire drills completed for the facility. Photographic evidence was obtained.

The Assistant Maintenance Director was present when the deficiency was identified.

The findings were reconfirmed at the exit conference at 11:00 a.m. 4/19/23 with the Assistant Maintenance Director. There was no Administrator on site to include in the exit conference.

NFPA 101 (2012 ed.) 19.7.1.6, 19.7.1.7