HospitalInspections.org

Based on observation and facility staff interview, the facility staff failed to provide a complete alarm notification system in one of one enclosed court yards. This deficient practice potentially could affect all residents, staff, and occupants in the event of a fire. The facility census was 4.

Observation on 5/11/22 during the facility tour showed the facility's enclosed court yard did not have an audible and visual fire alarm devices.

During an interview on 5/11/22 at 1:04 P.M., the Director of Operations stated the courtyard did not have an audible and visual fire alarm device.

NFPA 101, 2012: Occupant Notification is provided in accordance with 9.6.3 by audible and visual signals.

Based on observation and facility staff interview, facility staff failed to ensure transfer grills were not installed in corridors. One room had a transfer grill installed in the corridor wall. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure transfer grills were not installed in corridors has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was 4.

Observation on 5/11/22, during the building tour, showed a 15 inch by 15 inch transfer grill installed in the corridor wall. Observation showed the transfer grill installed in the corridor wall between the nutritional room and the corridor.

During an interview on 5/11/22 at 10:47 A.M., the Director of Operations confirmed the observation.


NFPA 101, 2012 edition, Section 19.3.6.4 states:

"19.3.6.4 Transfer Grilles.
19.3.6.4.1 Transfer grilles, regardless of whether they are
protected by fusible link-operated dampers, shall not be used
in corridor walls or doors."