Bringing transparency to federal inspections
Tag No.: K0321
Based on observation and interview, the facility failed to maintain the required separation for hazard areas. This has the potential of affecting approximately 7 patients and staff by possible allowing fire and smoke to spread from a hazard area. This facility has a capacity of 20 and census of 7 patients at the time of the survey.
Findings are:
On 3/7/2019 at 4:00 P.M., observations revealed that the facility failed to provide the required separation for the Bath across from the Labor/Delivery. This room at the time of the survey was used as a storage room. The corridor door to the Bath room was not self-closing.
During interview conducted on 3/7/2019 at 4:00 P.M., Maintenance personnel stated that they were aware of the storage and that they are looking for a place to store the items.
Tag No.: K0355
Based on observation and interview, the facility failed to maintain the required height for the storage of portable fire extinguishers. This has the potential of affecting approximately 7 patients and staff by failing to provide access to the portable fire extinguishers. This facility has a capacity of 20 and census of 7 patients at the time of the survey.
Findings are:
On 3/7/2019 between 1:00 P.M. and 4:30 P.M., observations revealed that the facility failed to provide the required storage height for the portable fire extinguishers located across from the lactation room and in the Administration hall. Fire extinguishers mounted in cabinets had the top of the handle measured at six feet above the floor. During interview conducted on 3/7/2019 between 1:00 P.M. and 4:30 P.M. 4:00 P.M., Maintenance personnel stated that they were unaware of the height requirement for the storage of portable fire extinguishers.
Tag No.: K0712
Based on observation and record review, the facility failed to conduct fire drills at one per shift per quarter. This has the potential of affecting approximately 7 patients and staff. This deficient practice has the potential to affect the readiness of the staff in the case of fire emergency. This facility has a capacity of 20 and census of 7 residents at the time of the survey.
Finding are:
On 3/7/2019 at 2:00 P.M., record review, the facility failed to conduct a fire drill for the first, second and third shifts in the third quarter of 2018.
During interview conducted on 3/7/2019 at 2:00 P.M., Maintenance personnel stated that there was a change in staff and that they were unaware that they were missing drills.