HospitalInspections.org

Based on observation and staff interview, the facility is not providing doors with single action locking mechanisms. This deficient practice would not prevent the spread of smoke. This facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observation and staff interview on 4/6/16 at 2:25 p.m. revealed two surgery room doors were equipped with deadbolt action locking mechanisms.

Maintenance Staff confirmed these observations during the survey process.

Based on observation, record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 6 patients.

Findings include:

Observation and review of the facility's fire drill records on 4/6/16 at 1:40 p.m., revealed the second shift fire drills had not been conducted for 3 out of the 4 quarters. Maintenance Staff verified this observation during the survey process.

Based on observation, staff interview and record review, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition. All smoke compartments in the building and all patients 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 6.

Findings include:

Observation, staff interview and record review of the facilities fire safety components on 4/6/16 at 1:30 p.m., revealed the annual testing of the building sprinkler system for 2016 had not been conducted and was now past due.

Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The census was 6 with a capacity of 25.

Findings include:

Observation and staff interview on 4/6/16 at 2:40 p.m., revealed one out of eleven sprinkler heads located in the Kitchen contained paint and had not been replaced. Maintenance Staff verified this observation during the survey process.

(A)
Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all compartments and all of the patients and staff. The facility has 25 certified beds and at the time of the survey the facility census was 6.

Findings include:

Documentation review and staff interview on 4/6/16 at 1:30 p.m., with Maintenance Staff revealed that facility could not provide documentation to show that the generator was running at 30 percent load of the facility while in a 30 minute monthly test. Maintenance Staff verified this observation during the survey process.


(B)
Based on observation and staff interview, the facility failed to provide a remote shutoff switch for generator as required. The deficient practice would affect four out of four smoke compartments and all of the patients and staff. The facility has 25 certified beds and at the time of the survey the facility census was 6.

Findings include:

Observation and staff interview on 4/6/16 at 1:30 p.m., revealed the absence of a remote shutoff switch for the generator in accordance with NFPA 110, 1999 edition, 3-5.5.6.

NFPA 110, 1999 edition 3-5.5.6

3-5.5.6* All level 1 and level 2 installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building

A3-5.5.6 For level 1 and level 2 systems located outdoors the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. "
Maintenance Staff verified these observations during the survey process.

Based on observation and staff interview, the facility is not providing doors with single action locking mechanisms. This deficient practice would not prevent the spread of smoke. This facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observation and staff interview on 4/6/16 at 2:25 p.m. revealed two surgery room doors were equipped with deadbolt action locking mechanisms.

Maintenance Staff confirmed these observations during the survey process.

Based on observation, record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 6 patients.

Findings include:

Observation and review of the facility's fire drill records on 4/6/16 at 1:40 p.m., revealed the second shift fire drills had not been conducted for 3 out of the 4 quarters. Maintenance Staff verified this observation during the survey process.

Based on observation, staff interview and record review, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition. All smoke compartments in the building and all patients 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 6.

Findings include:

Observation, staff interview and record review of the facilities fire safety components on 4/6/16 at 1:30 p.m., revealed the annual testing of the building sprinkler system for 2016 had not been conducted and was now past due.

Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The census was 6 with a capacity of 25.

Findings include:

Observation and staff interview on 4/6/16 at 2:40 p.m., revealed one out of eleven sprinkler heads located in the Kitchen contained paint and had not been replaced. Maintenance Staff verified this observation during the survey process.

(A)
Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all compartments and all of the patients and staff. The facility has 25 certified beds and at the time of the survey the facility census was 6.

Findings include:

Documentation review and staff interview on 4/6/16 at 1:30 p.m., with Maintenance Staff revealed that facility could not provide documentation to show that the generator was running at 30 percent load of the facility while in a 30 minute monthly test. Maintenance Staff verified this observation during the survey process.


(B)
Based on observation and staff interview, the facility failed to provide a remote shutoff switch for generator as required. The deficient practice would affect four out of four smoke compartments and all of the patients and staff. The facility has 25 certified beds and at the time of the survey the facility census was 6.

Findings include:

Observation and staff interview on 4/6/16 at 1:30 p.m., revealed the absence of a remote shutoff switch for the generator in accordance with NFPA 110, 1999 edition, 3-5.5.6.

NFPA 110, 1999 edition 3-5.5.6

3-5.5.6* All level 1 and level 2 installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building

A3-5.5.6 For level 1 and level 2 systems located outdoors the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. "
Maintenance Staff verified these observations during the survey process.