Survey date 2025-02-26 - inspection
FIRE SAFETY PLAN Fire Safety Plan A written health care occupancy fire safety plan shall provide for all of the following: (1) Use of alarms (2) Transmission of alarms to fire department (3) Emergency phone call to fire department (4) Response to alarms (5) Isolation of fire (6) Evacuation of immediate area (7) Evacuation of smoke compartment (8) Preparation of floors and building for evacuation (9) Extinguishment of fire (10) Location and operation of doors disguised with murals as permitted by 18/19.2.2.2.7. All health care occupancy personnel shall be instructed in the use of and response to fire alarms. All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions: (1) When the individual who discovers a fire must immediately go to the aid of an endangered person (2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan. 18.7.2.2 through 18.7.2.3.3, 19.7.2.2 through 19.7.2.3.3
No actual harm with a potential for minimal harm. The least severe class of CMS finding.
Corrected on 2025-03-28.