HospitalInspections.org

Based on observation, this facility failed to provide a firewall with a two-hour fire rating between the clinic and the hospital portion of the facility. The wall is penetrated above the lay-in ceiling tile with building services (pipes, ductwork) and should only have a penetration in the corridor passageway. This deficient practice affects all occupants including staff, visitors and residents in one (1) of eight (8) smoke zones. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

Observations on 08/04/10, at 11:12 a.m., revealed the two-hour firewall separating the Cresco Clinic and the dining room corridor had penetrations. These penetrations were above the ceiling tile directly above the Doctors Conference Room door. There was a three (3) blue, one (1) black and two (2) white communication wires with a 1/2 inch to 3/4 inch gap.

Maintenance Staff A verified this finding.

Based on observation, the facility failed to maintain a smoke tight ceiling. The building is composed of Type II protected construction and is required by the Life Safety Code 19.1.6.2, to maintain smoke tight ceilings if used for healthcare occupancy. This deficient practice affects all occupants of two (2) of eight (8) smoke zones, This facility has a capacity of 25 and a census of 8 residents.
Findings include:
1.) Observations on 08/04/10, at 10:29 a.m., revealed the Whirlpool room and Sitz Bath room in the Maternity wing were each missing an escution ring leaving a 1/2 inch gap around the sprinkler head.
2.) Observations on 08/04/10, at 10:47 a.m., revealed Room #234 had two (2) communication wires penetrating the ceiling above the duct work leaving a 1/4 inch to 1/2 inch gap.
Maintenance Staff verified these observations.

Based on observation, the facility failed to ensure that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. This deficient practice affects occupants in two (2) off eight 8) smoke zones, as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

1.) Observations on 08/04/10, at 10:11 a.m., revealed the door to the Cashiers office which is open to the corridor.
2.) Observations on 08/04/10, at 11:18 a.m., revealed the door to the Conference room at the end of the Dining Room corridor (southwest room) which is open to the corridor was held open with a wedge.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the hazardous areas from other areas by partitions and self-closing doors to ensure a one-hour fire-resistance rating. This deficient practice affects all occupants in two (2) of eight (8) smoke zones where the hazardous rooms are located, this deficient practice will not prevent the spread of fire and smoke, in the event of a fire. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

1.) Observations on 08/04/10, at 10:21 a.m., revealed the Central Sterile Room had a 4 inch x 8 inch hole in the ceiling for steam lines over the sterilizing equipment.
2.) Observations on 08/04/10, at 11:32 a.m., revealed the Oxygen Storage room had a sprinkler head penetrating the masonry wall that had a 3/4 inch to 1 inch gap.
3.) Observations on 08/04/10, at 11:34 a.m., revealed the Medical Gas Storage room had a sprinkler head penetrating the masonry wall that had a 3/4 inch to 1 inch gap.
4.) Observations on 08/04/10, at 11:38 a.m. , revealed the Soiled Utility, Clean Utility and Storage Room in the Emergency room/Surgery hallway did not have self-closures. These rooms were over 50 sqft and were 1 hour construction with 45 min rated doors.

Maintenance Staff A verified these observations.

Based on record review and interview the facility failed to document the emergency egress lighting annually. This deficient practice affects all patients, staff and visitors of the facility. This facility has a capacity of 60 and a census of 57 residents.

Findings include:

Observation on 08/04/10 of the facility's maintenance records, revealed that the documentation regarding the annual testing of the emergency battery lighting system was missing.

Maintenance Staff A verified this observation.

Based on record review and staff interview, the facility is not conducting fire drills at varied times during the year 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 8 residents.

Findings include:

Review of the facility's fire drill records on 08/04/10, revealed that fire drills were conducted with in an hour of each other on the evening shift through out the year reviewed. The Evening Shift (3-11p) were completed at the following times: 01/26/10 at 4:30 p.m., 04/20/10 at 5:15 p.m., 07/29/10 at 5:15 p.m. and 10/29/09 at 7:30 p.m.

Maintenance Staff A verified this observation.

(A.)
Based on observation, the facility failed to maintain the fire alarm system in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. 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 08/04/10, at 11:25 a.m., the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the Boiler Room electrical panel was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice.

(B.)
Based on observation and staff interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that an approved visible fire alarm strobe was provided to give visible warning of a fire 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:

1.) Observations on 08/04/10, at 10:38 a.m., revealed, the facility failed to provide a properly maintained fire alarm system. The fire alarm did not have a functioning visual strobe for the Public Restroom #224 in the Patient wing.
2.) Observations on 08/04/10, at 11:23 a.m., revealed the facility failed to provide a properly maintained fire alarm system. The fire alarm did not have a functioning visual strobe for the Men's and Women's staff locker rooms

(C.)
Based on observation, interview and record review, the facility failed to provided a properly tested and maintained fire alarm system. All of the facility including all residents, staff and visitors could be directly affected by the deficient practice. The facility has 25 certified beds and a census was 5.

Findings include:

Record review on 08/04/10, revealed that the last Fire Inspection report was from 11/18/09. Maintenance Staff advised that the system was scheduled to be inspected on 08/10/10 by the Fire Alarm Company.

Maintenance Staff A verified these observations.

Based on observation, this 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 that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

Observations 0n 08/04/10, from 9:00-1:00 p.m., revealed the following areas had smoke detectors within three (3) feet of the HVAC air diffusers:
1.) Physical Therapy Waiting Room.
2.) Pateint Room #206.
3.) Pateint Room #204.
4.) In the corridor between the Clinic and Dining Room.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all occupants including staff, visitors and residents in four (4) of eight (8) smoke zones. The facility had a capacity of 25 and a census of 5 at the time of survey.

Findings include:

Observations on 08/04/10, from 9:00 a.m. to 1:00 p.m., revealed the following sprinkler heads with dirt/ lint or other foreign material on the diffuser and fusible link/glass bulb.
1.) In the Administration Office three (3) of three (3) sprinkler heads were coated with dirt or lint.
2.) In the corridor next the the Physical Therapy room one (1) sprinkler head had a white substance on the fusible link and diffuser. This sprinkler head also had a brown liquid on the fusible link and arms.
3.) In the Physical Therapy room there was one (1) of six (6) sprinkler heads had a brown liquid on the fusible link and diffuser.
4.) In the Maternity ward nurses station two (2) of two (2) sprinkler heads were covered with dirt and lint on the fusible link and diffuser.
5.) In the Janitor closet #183 the sprinkler head had dirt/ lint covering the fusible link and diffuser.
6.) The dishwashing area of the kitchen the sprinkler head and a green colored substance on the fusible link arms and diffuser.
7.) In the kitchen eight (8) of sixteen (16) sprinkler heads were coated with dirt/lint and grease on the fusible link,diffuser and arms.

Maintenance Staff A verified these observations.

Based on observation the facility failed to maintain fire extinguishers as required. The deficient practice could affect approximately 5 staff in the kitchen. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

Observation on 08/04/10, at 11:09 a.m., revealed one (1) fire extinguisher in the kitchen was located on the sitting on the floor under the phone along the wall separating the dishwashing and serving area. This fire extinguisher was also obstructed by and dining cart.

Maintenance Staff A verified this observation.

Based on observation and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments of the and all of the residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 8.

Findings include:

Observation on 08/04/10, at 10:45 a.m. and 10:51 a.m., revealed the patient wing east exterior exit door and the East Surgery exterior exit door were not equipped with exterior lights connected tot he generator.

Maintenance Staff A verified these observations.