HospitalInspections.org

Based on observations, it was determined the facility was a two-story building and consisted of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with one-hour fire rated materials. This deficient practice affects occupants in 1 of 5 zones. The facility has a capacity of 25 and at the time of the survey had a census of 7.

Findings include:

Observations on 10-22-10, revealed the following:

1. There were numerous penetrations ranging from 1/2 inch to 3 inches around numerous items in Room 235.

2. There were missing ceiling tiles in the IT Room in the X-Ray area.

3. There were numerous penetrations ranging from 1/2 inch to 3 inches around numerous items in the Janitor's Closet in the X-Ray Area.

4. There were numerous penetrations ranging from 1/2 inch to 6 inches around numerous items in both Mechanical Rooms.

5. There were numerous penetrations ranging from 1/2 inch to 3 inches around numerous items in the Janitor's Closet by the Cafe.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants in 1 of 20 smoke zones as the doors would not prevent the spread of fire and smoke. The facility has a capacity for 25 and at the time of the survey the census was 7 residents.

Findings include:

Observations on 10-22-10, revealed the door to Room 226 did not latch properly when tested.

Based on observations, the facility failed to separate hazardous rooms from other areas. This deficient practice affects occupants in 1 of 20 smoke zones. The facility has a capacity for 25 and at the time of the survey the census was 7 residents.

Findings include:

Observations on 10-22-10, revealed the drop down door in the Pharmacy was not connected to the fire alarm.

(A)
Based on observation, this facility is not providing an all-weather surface from the Clinic Exit by Room 4, affecting occupants of the Clinic. This facility has a capacity of 25 with a census of 7 residents.

Findings include:

Observations on 10-22-10, revealed that there was not a hard surface path from the Clinic Exit by Room 4.

Based upon record review, the facility failed to hold fire drills at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 25 with a census of 7.

Findings include:

Record review on 10-22-10, revealed the following:

1. There was no drill conducted during the overnight shift of the 2nd quarter of 2010.

2. There was no drill conducted during the night and overnight shift of the 4th quarter of 2009.

Based on observation, the facility failed to properly install the fire alarm system in accordance with NFPA 72. This deficient practice affects 20 of 20 zones. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Observations on 10-22-10, revealed the following:

1. There was a horn strobe hanging off the wall by the Central Supply Storage.

2. There was no lock on the fire alarm breaker.

(A)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants. The facility has a capacity of 25 and a census of 7.

Findings include:

Record review of the fire alarm test records on 10-22-10, revealed the fire alarm had only been tested once in the past year.

(B)
Based on observation the facility failed to provide a properly protect and label the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Observations on 10-22-10, revealed the location of the fire alarm breaker was not marked on the fire alarm panel.

(C)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants. The facility has a capacity of 25 and a census of 7.

Findings include:

Record review on 10-22-10, revealed the fire alarm reports were not NFPA compliant.

Based on record review, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Record review on 10-22-10, revealed the following (according to the September of 2009 report):

1. There was no strobe in the southwest part of the Cafe

2. The Kitchen Dishwasher horn was inoperable.

3. The strobe in the 1st Floor Health Information area was missing.

4. The horn strobe in the Wellness Center was not working.

Based on observations, the facility failed to install the sprinkler system properly in accordance with National Fire Protection Association (NFPA) 13. This affects the entire facility. The facility has a census of 7 and a capacity of 25.

Findings include:

Observations on 10-22-10, revealed the following:

1. There was no sprinkler coverage in Room 311.

2. There was a missing escutcheon ring in the Janitor's Closet X-Ray Area.

3. There is no sprinkler coverage in the Maintenance IT Room.

4. There is no sprinkler coverage in the Janitor's Closet by the Cafe.

5. There were mixed type sprinkler heads in the Dictation Area.

6. There is no sprinkler coverage in the Housekeeping Locker Room.

7. There is no sprinkler coverage in the Freight Hallway.

8. There is no sprinkler coverage in the 200 Hallway patient rooms.

9. There is no sprinkler coverage in ICU.

(A)
Based on record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Record review on 10-22-10, revealed the facility was not conducting proper quarterly inspections.

(B)
Based on observations, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition, 2-4.1.4. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The facility has 25 certified beds and at the time of the revisit the census was 7.

Findings include:

Observations on 10-22-10, revealed there was only 1 quick response head in the head box.


(C)
Based on observations, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition. The facility has a capacity of 25 and a census of 7.

Findings include:

Observations on 10-22-10, revealed there were dirty sprinkler heads located throughout the building.

Based on observations, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. The facility has a capacity of 25 and at the time of the survey process the census was 7 residents.

Findings include:

Observations on 10-22-10, revealed the fire extinguisher in the Laundry Room was blocked by numerous items.

Based on observations and record review, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required in accordance with NFPA 96 and NFPA 17A. Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. Also an owner's inspection shall be completed monthly. The facility has a capacity of 25 and at the time of the survey process the census was 7 residents.

Findings include:

1. Record review on 10-22-10, revealed there was no documentation of the monthly owner's inspection of the wet chemical extinguishing system.

2. Record review on 10-22-10, revealed the hood and duct system was not connected to the fire alarm.

Based on observation, the facility failed to provide a clear path of egress to a public way. This affects 1 of 20. This facility has a capacity of 25 with a census of 7.

Findings include:

Observations on 10-22-10, revealed the 200 Hallway Wallaroos did not have self closers that shut them automatically.

Based on observation, the facility failed to provide proper storage of oxygen cylinders in accordance with the National Fire Protection Association (NFPA) Standard 99. This deficient practice affects occupants in 1 of 20 smoke zones. This facility has a capacity of 25 and at the time of the survey the census was 7.

Findings include:

Observations on 10-22-10, revealed a single oxygen tank in room 239 was not properly secured. Maintenance Staff A confirmed this observation during the survey process.

Based on record review, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has 25 licensed beds and at the time of the survey the facility census was 7.

Findings include:

Record review on 10-22-10, revealed the generator log did not indicate the hour meter reading.

Based on observations, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Observations on 10-22-10, revealed the following:

1. There was light switches and outlet covers missing and there were switches hanging out of the wall in Room 434.

2. There was an open junction box in the Janitor's Closet in the X-Ray Area.

3. There was an open junction box in the Janitor's Closet in the Assistant Director of Facilities Office.

Based on record review, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 7.

Findings include:

Record review of the facility's sprinkler system outage policy on 10-22-10, revealed the facility did not include in the policy that DIA, Fire Marshal's Office, Fire Department, and there insurance company should be called. The policy also did not include the phone numbers to those places either.

Based on record review, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 7.

Findings include:

Record review of the facility's sprinkler system outage policy on 10-22-10, revealed the facility did not include in the policy that DIA, Fire Marshal's Office, Fire Department, and there insurance company should be called. The policy also did not include the phone numbers to those places either.

Based on observations, it was determined the facility was a two-story building and consisted of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with one-hour fire rated materials. This deficient practice affects occupants in 1 of 5 zones. The facility has a capacity of 25 and at the time of the survey had a census of 7.

Findings include:

Observations on 10-22-10, revealed the following:

1. There were numerous penetrations ranging from 1/2 inch to 3 inches around numerous items in Room 235.

2. There were missing ceiling tiles in the IT Room in the X-Ray area.

3. There were numerous penetrations ranging from 1/2 inch to 3 inches around numerous items in the Janitor's Closet in the X-Ray Area.

4. There were numerous penetrations ranging from 1/2 inch to 6 inches around numerous items in both Mechanical Rooms.

5. There were numerous penetrations ranging from 1/2 inch to 3 inches around numerous items in the Janitor's Closet by the Cafe.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants in 1 of 20 smoke zones as the doors would not prevent the spread of fire and smoke. The facility has a capacity for 25 and at the time of the survey the census was 7 residents.

Findings include:

Observations on 10-22-10, revealed the door to Room 226 did not latch properly when tested.

Based on observations, the facility failed to separate hazardous rooms from other areas. This deficient practice affects occupants in 1 of 20 smoke zones. The facility has a capacity for 25 and at the time of the survey the census was 7 residents.

Findings include:

Observations on 10-22-10, revealed the drop down door in the Pharmacy was not connected to the fire alarm.

(A)
Based on observation, this facility is not providing an all-weather surface from the Clinic Exit by Room 4, affecting occupants of the Clinic. This facility has a capacity of 25 with a census of 7 residents.

Findings include:

Observations on 10-22-10, revealed that there was not a hard surface path from the Clinic Exit by Room 4.

Based upon record review, the facility failed to hold fire drills at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 25 with a census of 7.

Findings include:

Record review on 10-22-10, revealed the following:

1. There was no drill conducted during the overnight shift of the 2nd quarter of 2010.

2. There was no drill conducted during the night and overnight shift of the 4th quarter of 2009.

Based on observation, the facility failed to properly install the fire alarm system in accordance with NFPA 72. This deficient practice affects 20 of 20 zones. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Observations on 10-22-10, revealed the following:

1. There was a horn strobe hanging off the wall by the Central Supply Storage.

2. There was no lock on the fire alarm breaker.

(A)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants. The facility has a capacity of 25 and a census of 7.

Findings include:

Record review of the fire alarm test records on 10-22-10, revealed the fire alarm had only been tested once in the past year.

(B)
Based on observation the facility failed to provide a properly protect and label the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Observations on 10-22-10, revealed the location of the fire alarm breaker was not marked on the fire alarm panel.

(C)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants. The facility has a capacity of 25 and a census of 7.

Findings include:

Record review on 10-22-10, revealed the fire alarm reports were not NFPA compliant.

Based on record review, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) 72. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Record review on 10-22-10, revealed the following (according to the September of 2009 report):

1. There was no strobe in the southwest part of the Cafe

2. The Kitchen Dishwasher horn was inoperable.

3. The strobe in the 1st Floor Health Information area was missing.

4. The horn strobe in the Wellness Center was not working.

Based on observations, the facility failed to install the sprinkler system properly in accordance with National Fire Protection Association (NFPA) 13. This affects the entire facility. The facility has a census of 7 and a capacity of 25.

Findings include:

Observations on 10-22-10, revealed the following:

1. There was no sprinkler coverage in Room 311.

2. There was a missing escutcheon ring in the Janitor's Closet X-Ray Area.

3. There is no sprinkler coverage in the Maintenance IT Room.

4. There is no sprinkler coverage in the Janitor's Closet by the Cafe.

5. There were mixed type sprinkler heads in the Dictation Area.

6. There is no sprinkler coverage in the Housekeeping Locker Room.

7. There is no sprinkler coverage in the Freight Hallway.

8. There is no sprinkler coverage in the 200 Hallway patient rooms.

9. There is no sprinkler coverage in ICU.

(A)
Based on record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Record review on 10-22-10, revealed the facility was not conducting proper quarterly inspections.

(B)
Based on observations, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition, 2-4.1.4. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The facility has 25 certified beds and at the time of the revisit the census was 7.

Findings include:

Observations on 10-22-10, revealed there was only 1 quick response head in the head box.


(C)
Based on observations, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition. The facility has a capacity of 25 and a census of 7.

Findings include:

Observations on 10-22-10, revealed there were dirty sprinkler heads located throughout the building.

Based on observations, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. The facility has a capacity of 25 and at the time of the survey process the census was 7 residents.

Findings include:

Observations on 10-22-10, revealed the fire extinguisher in the Laundry Room was blocked by numerous items.

Based on observations and record review, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required in accordance with NFPA 96 and NFPA 17A. Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. Also an owner's inspection shall be completed monthly. The facility has a capacity of 25 and at the time of the survey process the census was 7 residents.

Findings include:

1. Record review on 10-22-10, revealed there was no documentation of the monthly owner's inspection of the wet chemical extinguishing system.

2. Record review on 10-22-10, revealed the hood and duct system was not connected to the fire alarm.

Based on observation, the facility failed to provide a clear path of egress to a public way. This affects 1 of 20. This facility has a capacity of 25 with a census of 7.

Findings include:

Observations on 10-22-10, revealed the 200 Hallway Wallaroos did not have self closers that shut them automatically.

Based on observation, the facility failed to provide proper storage of oxygen cylinders in accordance with the National Fire Protection Association (NFPA) Standard 99. This deficient practice affects occupants in 1 of 20 smoke zones. This facility has a capacity of 25 and at the time of the survey the census was 7.

Findings include:

Observations on 10-22-10, revealed a single oxygen tank in room 239 was not properly secured. Maintenance Staff A confirmed this observation during the survey process.

Based on record review, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and residents. The facility has 25 licensed beds and at the time of the survey the facility census was 7.

Findings include:

Record review on 10-22-10, revealed the generator log did not indicate the hour meter reading.

Based on observations, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility has a capacity of 25 and a census of 7 residents.

Findings include:

Observations on 10-22-10, revealed the following:

1. There was light switches and outlet covers missing and there were switches hanging out of the wall in Room 434.

2. There was an open junction box in the Janitor's Closet in the X-Ray Area.

3. There was an open junction box in the Janitor's Closet in the Assistant Director of Facilities Office.

Based on record review, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 7.

Findings include:

Record review of the facility's sprinkler system outage policy on 10-22-10, revealed the facility did not include in the policy that DIA, Fire Marshal's Office, Fire Department, and there insurance company should be called. The policy also did not include the phone numbers to those places either.

Based on record review, this facility failed to provide the policy in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 7.

Findings include:

Record review of the facility's sprinkler system outage policy on 10-22-10, revealed the facility did not include in the policy that DIA, Fire Marshal's Office, Fire Department, and there insurance company should be called. The policy also did not include the phone numbers to those places either.