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PINNACLE POINTE BEHAVIORAL HEALTH SYSTEM
Fire Alarm System - Initiation
Tag No.: K0342
Based on observation, record reviews and interviews on February 5, 2019, the facility failed to provide for a properly maintained and tested fire alarm system with approved functioning components. The deficient practice affected at least one smoke compartments and all staff and residents.
Findings include:
1. At 10:40 am during inspection of fire dampers in the facility fire alarm system with the assistance of the Engineering Supervisor, a fire damper was observed to be bent and distorted such that it would not function properly to the closed position to prevent the spread of smoke and fire. The Engineering Supervisor confirmed the finding.
2. At 1:10 p.m. record review of fire alarm components revealed damper and fusible link inspections occurred in 2015; however, more recent records could not confirm if fusible links were being inspected or actuated. The Engineering Supervisor confirmed the finding and indicated he did not have any other records.
Portable Fire Extinguishers
Tag No.: K0355
Based on observation, record reviews and interviews on February 5, 2019, the facility failed to provide for a properly maintained fire extinguishers. The deficient practice affected any and all patient who are transported in the van.
Findings include:
1. At 9:45 am during inspection of a van the fire extinguisher was no record of inspection for January, 2019 and the fire extinguisher was not fully charged. Maintenance staff noted it had been used, but didn't know who used it.
Smoking Regulations
Tag No.: K0741
Based on observation and interviews on February 5, 2019, the facility failed to provide metal containers with self-closing cover devices for designated outdoor smoking areas. The deficient practice potentially affected all staff and residents.
Findings Include:
1. At 3:45 pm a smoking area was observed adjacent to a gas meter and had a bench. Cigarette butts were noted on the ground near vegetation, by the gas meter and on the parking lot. There were no ashtrays of safe design or self closing metal containers. An interview with the administrator indicated he was aware of the area, but said it was off the property.