HospitalInspections.org

Based on record review and interview the facility failed to ensure the documentation and completion of fire drills quarterly per shift. This failed practiced placed all residents, staff and visitors at risk for delay in response during a fire emergency due to inadequate staff training.

Record review on 9/10/15 revealed no documentation of proper fire drills conducted during the review period of 2014-2015.

During an interview on 9/10/15 the Facility Supervisor stated he was new to the Supervisor role and was only doing that they had done in the past



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Based on record review and interview the facility failed to ensure quarterly sprinkler inspections were completed in accordance to NFPA 72 National Fire Alarm Code. This failed practice placed the all residents, staff and visitors at risk of exposure to a smoke and fire environment due to the potential of a failed unmaintained fire alarm system.

Record review on 9/10/15 revealed no quarterly inspections were conducted on the facility ' s fire alarm system.

Facility Supervisor acknowledged the findings at the time of discovery.



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Based on record review and interview the facility failed to ensure the completion and documentation of the kitchen hood suppression system inspections and the cleaning of the exhaust system at appropriate intervals. This failed practiced placed residents, staff and visitors at risk for loss of dietary service and exposure to a smoke and fire environment.

Record review on 9/10/15 revealed the facility had the hood suppression system inspected on 4/7/15. No additional inspection had been conducted with in six months prior to 4/7/15. Additional review revealed no complete hood cleaning had been conducted from the filters to the duct termination.

The Facility Supervisor acknowledged the findings at the time of discovery.



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Based on observation, record review and interview the facility failed to ensure: 1) the generator contained a remote manual stop button and 2) documentation and completion of appropriate and timely inspections, tests, exercising and maintenance of the emergency generator were in accordance with NFPA 99 Standard for Health Care Facilities and NFPA 110 Standard for Emergency and Standby Power Systems. This failed practice placed the all residents, staff and visitors at risk of loss emergency electrical services.

Observation on 9/10/15 revealed the generator set and housing did not contain a remote manual stop button outside of the generator room.

Record review on 9/10/15 revealed no documentation of weekly inspections or annual load testing on the emergency generator.

The Facility Supervisor acknowledged the findings at the time of discovery.



.

Based on record review and interview the facility failed to ensure the documentation and completion of fire drills quarterly per shift. This failed practiced placed all residents, staff and visitors at risk for delay in response during a fire emergency due to inadequate staff training.

Record review on 9/10/15 revealed no documentation of proper fire drills conducted during the review period of 2014-2015.

During an interview on 9/10/15 the Facility Supervisor stated he was new to the Supervisor role and was only doing that they had done in the past



.

Based on record review and interview the facility failed to ensure quarterly sprinkler inspections were completed in accordance to NFPA 72 National Fire Alarm Code. This failed practice placed the all residents, staff and visitors at risk of exposure to a smoke and fire environment due to the potential of a failed unmaintained fire alarm system.

Record review on 9/10/15 revealed no quarterly inspections were conducted on the facility ' s fire alarm system.

Facility Supervisor acknowledged the findings at the time of discovery.



.

Based on record review and interview the facility failed to ensure the completion and documentation of the kitchen hood suppression system inspections and the cleaning of the exhaust system at appropriate intervals. This failed practiced placed residents, staff and visitors at risk for loss of dietary service and exposure to a smoke and fire environment.

Record review on 9/10/15 revealed the facility had the hood suppression system inspected on 4/7/15. No additional inspection had been conducted with in six months prior to 4/7/15. Additional review revealed no complete hood cleaning had been conducted from the filters to the duct termination.

The Facility Supervisor acknowledged the findings at the time of discovery.



.

Based on observation, record review and interview the facility failed to ensure: 1) the generator contained a remote manual stop button and 2) documentation and completion of appropriate and timely inspections, tests, exercising and maintenance of the emergency generator were in accordance with NFPA 99 Standard for Health Care Facilities and NFPA 110 Standard for Emergency and Standby Power Systems. This failed practice placed the all residents, staff and visitors at risk of loss emergency electrical services.

Observation on 9/10/15 revealed the generator set and housing did not contain a remote manual stop button outside of the generator room.

Record review on 9/10/15 revealed no documentation of weekly inspections or annual load testing on the emergency generator.

The Facility Supervisor acknowledged the findings at the time of discovery.



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