HospitalInspections.org

Based on observation and staff interviews it was determined the facility failed to maintain the smoke compartment smoke barrier separation walls in a manner compliant with NFPA 101 Chapter 19 and Chapter 8.

This could place all residents at risk in the event of fire

The findings include:

During a tour of the facility with Staff M on 04/16/2019 Between 11:00 am and 6:00 pm observation revealed that the fire barrier separating the two smoke compartments was not properly sealed as required by NFPA 101 Chapter 19 and Chapter 8.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 Edition NFPA 101, Chapter 19, Section 19.3.7 Chapter 8, Section 8.5

Based on review of records and staff interviews it was determined the facility failed to maintain fire drills on all three shifts once per quarter as required by NFPA 101, Chapter 19.

This could place all residents at risk in the event of fire

The findings include:

During a tour of the facility with Staff M on 04/16/2019 Between 11:00 am and 6:00 pm observation revealed that the facility had not performed the required fire drills as required by NFPA 101 Chapter 19 and Chapter 7 during:

The first quarter of 2019 on the first and second shifts;
The fourth quarter of 2018 on all three shifts;
the third quarter of 2018 on the first and second shifts;

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 Edition NFPA 101, Chapter 19, Section 19.7.1.6.

Based on review of records and staff interviews it was determined the facility failed to maintain annual fire door inspections as required by NFPA 101, Chapter 19 and NFPA 80.

This could place all residents at risk in the event of fire

The findings include:

During a tour of the facility with Staff M on 04/16/2019 Between 11:00 am and 6:00 pm observation revealed that the facility had not performed the required annual fire door inspections as required by NFPA 101 and NFPA 80.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 Edition NFPA 101 Chapter 19, Section 19.3.6.3.3 and NFPA 80 Chapter 5, 5.2.