HospitalInspections.org

Based on observation, interview, and documentation review the facility failed to ensure the fire alarm system functioned according to NFPA 72, fire rated doors on self closing devices closed to a latching position according to NFPA 101, and the walls in the stairwell were secure (710). This has the potential to affect all patients at the facility. The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of patients.

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients receiving services at the facility. The facility census was 17.
Findings include:
1. Observation of the stairs leading from the facility to the first floor in the administrative hallway identified as a route visitors use to see patients completed on 03/14/16 revealed pealing paint and cracks in the wall at ceiling level with pieces of the wall falling to the floor on the platform above the door to the facility. These findings were verified by Staff C at the time of the observation. No identifiable work orders were noted to fix the stairwell walls.

Interview with Staff C completed on 03/15/16 at 9:15 AM revealed he/she does not know why the wall is cracking and pieces are falling off but Staff C stated he/she certainly wants to get the area corrected because it can be used by visitors to the facility.

2. Please see K29 for findings related to the facility failing to ensure doors in hazardous areas with self closing devices closed to latching position.
3. Please see K51 for the findings related to the facility failing to ensure the fire alarm system functioned appropriately.