HospitalInspections.org

Based on observation and interview, the facility failed to maintain the stair enclosure free of combustible material. This has the potential of affecting approximately 12 occupants in one of six smoke zones, by possible allowing stair enclosure to become affected by fire. This facility has a capacity of 25 and census of 12 patients at the time of the survey.

Findings are:

On 7/29/24 at 1:15 P.M., observations revealed that the facility failed to prohibit the storage of items within the West stair enclosure.

During interview conducted on 7/29/24 at 1:15 P.M., Maintenance personnel stated that they were unaware that there were items stored within the stair enclosure.

Based on observation and interview, the facility failed to maintain the required separation for hazardous areas. This has the potential of affecting approximately 12 occupants in one of six smoke zones, by allowing fire and smoke to spread from a hazardous area. This facility has a capacity of 25 and census of 12 residents at the time of the survey.

Findings are:

On 7/29/24 at 1:50 P.M., observations revealed that the facility failed to provide the required self-closing door for North Equipment Room that is being used for storage.

During interview conducted on 7/29/2024 at 1:50 P.M., Maintenance personnel stated that they were unaware that the door was required to be self-closing.

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 12 occupants in six of six smoke zones. 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 25 and census of 12 patients at the time of the survey.

Finding are:

On 7/29/2024 at 12:00 P.M., record review, the facility failed to conduct a fire drill for the first and second shifts of the first and second quarter of 2024, the second and third shift of the third quarter of 2023, and the first and second shifts of the four quarter of 2023.

During interview conducted on 7/29/2024 at 12:00 P.M., Maintenance personnel stated that they were unaware of the missing drills.

Based on record review and interview, the facility failed to provide annual inspections and testing for fire door assemblies. This deficient practice has the potential to allow the spread of fire or smoke throughout the smoke zones. This deficient practice has the potential to affect all occupants in six of six smoke zones. Facility has the capacity of 25 with a census 12 patients at the time of the survey.

Findings are:
Record review on 7/29/2024 at 12:30 P.M. revealed the records for the annual inspection and testing for the fire door assemblies were not available for review.

During an interview on 7/29/2024 at 12:30 P.M. Maintenance Personnel indicated that they did not have the records of the door inspections.