HospitalInspections.org

Based on observation, this facility is not assuring that one of four smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. 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 8.

Findings include:

Observations on 03/31/10 at 12:09 p.m., revealed the 2nd Floor Main Lobby smoke barrier contained a 1/2 inch conduit with a one fourth inch gap above the lay in tile. According to the facility layout, this was a required barrier.

Maintenance Staff B verified this observation.

Based on observation, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the two smoke compartments on this floor. This could affect all residents, staff and visitors on this floor. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3/31/2010 at 12:08 p.m., revealed facility failed to maintain the smoke doors located in the 2nd floor Main Lobby. These smoke doors failed to close completely while being tested.

2. Observations on 3/31/2010 at 11:45 a.m., revealed facility failed to maintain the O.B. smoke doors located in the 3rd floor. These smoke doors failed to close completely while tested.

Maintenance Staff B verified this observation.

Based on observation, this facility is not providing unobstructed corridors that provide a clear path of egress for one of three floors. These projections on the wall in one corridor could effect all residents, staff and visitors on the second floor. The facility has a capacity of 25 with a census of 8.

Findings include:

Observations on 03/31/10 at 11:58 a.m., revealed the facility failed to maintain the hinged charting stations in the corridor. The charting stations located near resident room #205, #211, #216, #217 and #221 were not maintained to retract to the closed position after each use and would obstruct the corridor in the event of an emergency.

Maintenance Staff A verified this observation.

Based on observation, the facility failed to provide a properly tested and maintained fire alarm system. All of the building smoke compartments, residents and staff would be directly affected by the deficient practice. The facility has a capacity of 25 and at census of 8.

Findings include:

1. Observations on 03/31/2010 at 2:20 p.m., the fire alarm system was tested throughout the building. One of the interface/control functions tested on the fire alarm system failed to operate properly. The double fire/ smoke doors located near the Old Central Supply Room failed to close upon the activation of the Fire Alarm System.

2. Observations on 03/31/2010 at 2:35 p.m., the fire alarm system was tested throughout the building. One of the interface/control functions tested on the fire alarm system failed to operate properly. While simulating a low battery and phone line trouble the Automatic Dialer located in Boiler Room failed to send an audible/visible signal to the Main Fire Alarm Panel or remote Annunciator Fire Alarm Panel located in the 2nd floor Nurse Station.

Maintenance Staff A verified this observation.

Based on observation, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect all occupants of the building. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 03/31/2010 at 11:47 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near Outpatient Room #3. This corridor contained a smoke detector with in three feet of an air diffuser.


2. Observations on 03/31/2010 at 11:52 a.m., revealed the facility failed to maintain the Fire Alarm System in the 2nd Floor Kitchenette. This room contained a smoke detector with in three feet of an air diffuser.

3. Observations on 03/31/2010 at 2:14 p.m., revealed the facility failed to maintain the Fire Alarm System in the Boiler Room. This room contained a smoke detector with in three feet of an air diffuser.

4. Observations on 03/31/2010 at 1:27 p.m., revealed the facility failed to maintain the Fire Alarm System in the Radiology Waiting Room. This room contained a smoke detector with in three feet of an air diffuser.

Based on observations, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads are free of foreign material and obstructions. This could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 8.

Findings include:

1. Observations on 03/31/2010 at 11:30 a.m., revealed the facility failed to maintain the sprinkler system in the 3rd floor Storage Room. This room contained boxes of Catheters being stored with in six inches of the sprinkler head deflector.

2. Observations on 03/31/2010 at 11:56 a.m., revealed the facility failed to maintain the sprinkler system in the Mens 2nd floor Operating Room Locker Room. This bathroom contained a sprinkler head with paint on the fusible link and deflector.

Maintenance Staff B verified this observation.

Based on observations and record review, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. This has the potential of affecting all the residents and staff. This facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations and record review on 03/31/2010 at 11:39 a.m., revealed the vinyl mini blinds located in the Nursery were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant.

2. Observations and record review on 03/31/2010 at 11:55 a.m., revealed the vinyl mini blinds located in the 2nd floor Report Room were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant.

3. Observations and record review on 03/31/2010 at 1:30 p.m., revealed the vinyl mini blinds located in the Quality Assurance Coordinators Office were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant.

Maintenance Staff A verified these observations.

Based on observation, 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, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 8.

Findings Include:

1. Observations on 03/31/10 at 11:35 a.m., revealed the facility failed to maintain the electrical system in the 3rd floor corridor. Electrical breaker #52 in Electrical Panel 3-NI was not identified or labeled in the electrical panel directory.

2. Observations on 03/31/10 at 2:20 p.m., revealed the facility failed to maintain the electrical system in Radiology Room #2. This room contained a black extension cord supplying electrical power to an X-Ray viewer.

3. Observations on 03/31/10 at 12:00 p.m., revealed the facility failed to maintain the electrical system in the 2nd floor Electrical Room. Electrical breakers #36, #40, #42, #44, #46 and #54 in Electrical Panel 2-N7 were not identified or labeled in the electrical panel directory.

4. Observations on 03/31/10 at 12:01 p.m., revealed the facility failed to maintain the electrical system in the 2nd floor Electrical Room. Electrical breakers #14, #16, #19, and #21 in Electrical Panel 2-L2 were not identified or labeled in the electrical panel directory.

5. Observations on 03/31/10 at 12:02 p.m., revealed the facility failed to maintain the electrical system in the 2nd floor Electrical Room. Electrical breakers #23 and #24 in Electrical Panel 2-C4 were not identified or labeled in the electrical panel directory.

6. Observations on 03/31/10 at 2:10 p.m., revealed the facility failed to maintain the electrical system in the Basement Electrical Room. Electrical breakers #21, #23, #35, #27, #28, #29, #30, #31, #32 and #33 in Electrical Panel 1-N5 were not identified or labeled in the electrical panel directory.

7. Observations on 03/31/10 at 1:10 p.m., revealed the facility failed to maintain the electrical system in the Healthy Lifestyles Center Electrical Room. Electrical breakers #21, #24 and #34 in Electrical Panel 1-MOB were not identified or labeled in the electrical panel directory.

8. Observations on 03/31/10 at 1:11 p.m., revealed the facility failed to maintain the electrical system in the Healthy Lifestyles Center Electrical Room. Electrical breakers #12, #14, #16, #18, #19, #20, #21 and #22 in Electrical Panel 2-C6 were not identified or labeled in the electrical panel directory.

9. Observations on 03/31/10 at 1:12 p.m., revealed the facility failed to maintain the electrical system in the Healthy Lifestyles Center Electrical Room. Electrical breakers #34, #35, #49, #53, #55 and #56 in Electrical Panel 2-N6 were not identified or labeled in the electrical panel directory.

10. Observations on 03/31/10 at 1:28 p.m., revealed the facility failed to maintain the electrical system in Radiology Office. This room contained a surge supplying electrical power to a fan.

11. Observations on 03/31/10 at 1:54 p.m., revealed the facility failed to maintain the electrical system in Respiratory Therapy Office. This room contained a surge supplying electrical power to a fan.

Maintenance Staff B verified this observation.

Based on staff interview and record review, this facility is not assuring that a policy is 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. The lack of procedures could effect the actions taken by staff in the event of an emergency. 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 8.

Findings include:

Record review and interview on 03/31/2010 at 11:23 a.m., revealed the facility failed to have an outage policy regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in a twenty-four hour period.

Based on staff interview and record review, this facility is not assuring that a policy is 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. The lack of procedures could effect the actions taken by staff in the event of an emergency. 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 8.

Findings include:

Record review and interview on 03/31/2010 at 11:23 a.m., revealed the facility failed to have an outage policy regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in a twenty-four hour period.

Based on observation, this facility is not assuring that one of four smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. 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 8.

Findings include:

Observations on 03/31/10 at 12:09 p.m., revealed the 2nd Floor Main Lobby smoke barrier contained a 1/2 inch conduit with a one fourth inch gap above the lay in tile. According to the facility layout, this was a required barrier.

Maintenance Staff B verified this observation.

Based on observation, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the two smoke compartments on this floor. This could affect all residents, staff and visitors on this floor. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3/31/2010 at 12:08 p.m., revealed facility failed to maintain the smoke doors located in the 2nd floor Main Lobby. These smoke doors failed to close completely while being tested.

2. Observations on 3/31/2010 at 11:45 a.m., revealed facility failed to maintain the O.B. smoke doors located in the 3rd floor. These smoke doors failed to close completely while tested.

Maintenance Staff B verified this observation.

Based on observation, this facility is not providing unobstructed corridors that provide a clear path of egress for one of three floors. These projections on the wall in one corridor could effect all residents, staff and visitors on the second floor. The facility has a capacity of 25 with a census of 8.

Findings include:

Observations on 03/31/10 at 11:58 a.m., revealed the facility failed to maintain the hinged charting stations in the corridor. The charting stations located near resident room #205, #211, #216, #217 and #221 were not maintained to retract to the closed position after each use and would obstruct the corridor in the event of an emergency.

Maintenance Staff A verified this observation.

Based on observation, the facility failed to provide a properly tested and maintained fire alarm system. All of the building smoke compartments, residents and staff would be directly affected by the deficient practice. The facility has a capacity of 25 and at census of 8.

Findings include:

1. Observations on 03/31/2010 at 2:20 p.m., the fire alarm system was tested throughout the building. One of the interface/control functions tested on the fire alarm system failed to operate properly. The double fire/ smoke doors located near the Old Central Supply Room failed to close upon the activation of the Fire Alarm System.

2. Observations on 03/31/2010 at 2:35 p.m., the fire alarm system was tested throughout the building. One of the interface/control functions tested on the fire alarm system failed to operate properly. While simulating a low battery and phone line trouble the Automatic Dialer located in Boiler Room failed to send an audible/visible signal to the Main Fire Alarm Panel or remote Annunciator Fire Alarm Panel located in the 2nd floor Nurse Station.

Maintenance Staff A verified this observation.

Based on observation, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect all occupants of the building. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 03/31/2010 at 11:47 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near Outpatient Room #3. This corridor contained a smoke detector with in three feet of an air diffuser.


2. Observations on 03/31/2010 at 11:52 a.m., revealed the facility failed to maintain the Fire Alarm System in the 2nd Floor Kitchenette. This room contained a smoke detector with in three feet of an air diffuser.

3. Observations on 03/31/2010 at 2:14 p.m., revealed the facility failed to maintain the Fire Alarm System in the Boiler Room. This room contained a smoke detector with in three feet of an air diffuser.

4. Observations on 03/31/2010 at 1:27 p.m., revealed the facility failed to maintain the Fire Alarm System in the Radiology Waiting Room. This room contained a smoke detector with in three feet of an air diffuser.

Based on observations, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads are free of foreign material and obstructions. This could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 8.

Findings include:

1. Observations on 03/31/2010 at 11:30 a.m., revealed the facility failed to maintain the sprinkler system in the 3rd floor Storage Room. This room contained boxes of Catheters being stored with in six inches of the sprinkler head deflector.

2. Observations on 03/31/2010 at 11:56 a.m., revealed the facility failed to maintain the sprinkler system in the Mens 2nd floor Operating Room Locker Room. This bathroom contained a sprinkler head with paint on the fusible link and deflector.

Maintenance Staff B verified this observation.

Based on observations and record review, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. This has the potential of affecting all the residents and staff. This facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations and record review on 03/31/2010 at 11:39 a.m., revealed the vinyl mini blinds located in the Nursery were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant.

2. Observations and record review on 03/31/2010 at 11:55 a.m., revealed the vinyl mini blinds located in the 2nd floor Report Room were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant.

3. Observations and record review on 03/31/2010 at 1:30 p.m., revealed the vinyl mini blinds located in the Quality Assurance Coordinators Office were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant.

Maintenance Staff A verified these observations.

Based on observation, 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, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 8.

Findings Include:

1. Observations on 03/31/10 at 11:35 a.m., revealed the facility failed to maintain the electrical system in the 3rd floor corridor. Electrical breaker #52 in Electrical Panel 3-NI was not identified or labeled in the electrical panel directory.

2. Observations on 03/31/10 at 2:20 p.m., revealed the facility failed to maintain the electrical system in Radiology Room #2. This room contained a black extension cord supplying electrical power to an X-Ray viewer.

3. Observations on 03/31/10 at 12:00 p.m., revealed the facility failed to maintain the electrical system in the 2nd floor Electrical Room. Electrical breakers #36, #40, #42, #44, #46 and #54 in Electrical Panel 2-N7 were not identified or labeled in the electrical panel directory.

4. Observations on 03/31/10 at 12:01 p.m., revealed the facility failed to maintain the electrical system in the 2nd floor Electrical Room. Electrical breakers #14, #16, #19, and #21 in Electrical Panel 2-L2 were not identified or labeled in the electrical panel directory.

5. Observations on 03/31/10 at 12:02 p.m., revealed the facility failed to maintain the electrical system in the 2nd floor Electrical Room. Electrical breakers #23 and #24 in Electrical Panel 2-C4 were not identified or labeled in the electrical panel directory.

6. Observations on 03/31/10 at 2:10 p.m., revealed the facility failed to maintain the electrical system in the Basement Electrical Room. Electrical breakers #21, #23, #35, #27, #28, #29, #30, #31, #32 and #33 in Electrical Panel 1-N5 were not identified or labeled in the electrical panel directory.

7. Observations on 03/31/10 at 1:10 p.m., revealed the facility failed to maintain the electrical system in the Healthy Lifestyles Center Electrical Room. Electrical breakers #21, #24 and #34 in Electrical Panel 1-MOB were not identified or labeled in the electrical panel directory.

8. Observations on 03/31/10 at 1:11 p.m., revealed the facility failed to maintain the electrical system in the Healthy Lifestyles Center Electrical Room. Electrical breakers #12, #14, #16, #18, #19, #20, #21 and #22 in Electrical Panel 2-C6 were not identified or labeled in the electrical panel directory.

9. Observations on 03/31/10 at 1:12 p.m., revealed the facility failed to maintain the electrical system in the Healthy Lifestyles Center Electrical Room. Electrical breakers #34, #35, #49, #53, #55 and #56 in Electrical Panel 2-N6 were not identified or labeled in the electrical panel directory.

10. Observations on 03/31/10 at 1:28 p.m., revealed the facility failed to maintain the electrical system in Radiology Office. This room contained a surge supplying electrical power to a fan.

11. Observations on 03/31/10 at 1:54 p.m., revealed the facility failed to maintain the electrical system in Respiratory Therapy Office. This room contained a surge supplying electrical power to a fan.

Maintenance Staff B verified this observation.

Based on staff interview and record review, this facility is not assuring that a policy is 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. The lack of procedures could effect the actions taken by staff in the event of an emergency. 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 8.

Findings include:

Record review and interview on 03/31/2010 at 11:23 a.m., revealed the facility failed to have an outage policy regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in a twenty-four hour period.

Based on staff interview and record review, this facility is not assuring that a policy is 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. The lack of procedures could effect the actions taken by staff in the event of an emergency. 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 8.

Findings include:

Record review and interview on 03/31/2010 at 11:23 a.m., revealed the facility failed to have an outage policy regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in a twenty-four hour period.