HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure the fire-extinguishing system nozzles protecting the kitchen cooking equipment and exhaust hood were aimed properly and not blocked. This condition did not ensure the reliability of the system, and increased the potential that the suppression system would not operate as designed during a cooking fire. The facility has a capacity of 23, with a census of 2 on the day of survey.

Findings are:
Observation on 6-25-24, at 10:55 am revealed the kitchen range hood suppression system nozzles were not properly aimed and that new appliances were installed with upper shelves that blocked the nozzles from covering the entire cooking surface.

During an interview on 6-25-24, at 10:55 am, Maintenance A confirmed the findings.

Based on observation and interview, the facility failed to assure smoke barrier doors would prevent the passage of smoke and gases. This deficient practice would allow smoke and gases to migrate to another smoke compartment. The facility has a capacity of 23 and a census of 2 on the day of survey.

Findings are:
Observations on 6-25-24 at 11:45 am revealed the west smoke door between the employee entrance and the surgery area failed to properly close and latch within the doorframe.

During an interview on 6-25-24 at 11:45 am, Maintenance Staff A confirmed the findings.