HospitalInspections.org

Based on observation and a review of documents, the facility fails to assure a proper 2 hour fire rated separation to a non-conforming building. The deficient practice compromises the fire-resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting 3 of 3 smoke zones. The facility has a capacity of 40 with a census of 36 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/2010, between 2:00 p.m. and 6:00 p.m., unsealed gaps around wires, pipes and conduit were observed in designated 2-hour rated walls near the Pharmacy and near the Diet Kitchen.

Staff A and B were present, aware of the findings, and acknowledged the presence of unsealed gaps in the designated fire walls.

Based upon observation and staff interview, the facility failed to assure that hazardous areas are protected by one hour fire rated construction. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/10, between 2:00 p.m. and 6:00 p.m., it is observed that corridor doors to a storage room near the facility's boiler room are not self-closing.

Staff A and B were present and acknowledged the findings. Staff A stated that he would obtain and install closers on the doors to ensure that the doors are self-closing.

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/10, between 2:00 p.m. and 6:00 p.m., a review of records for the last 4 quarters revealed the following:

-- 1. Fire drills are conducted within close proximity of each other:
a. Fire Drills for the 2nd Shift, 2nd, 3rd, 4th Qtr 2009 and 1st Qtr 2009, were held at 6:30 a.m., 6:15 a.m., 6:15 a.m. and 5:45 a.m., respectively.

Staff A and B were present and acknowledged the results of the record review.

Based upon a review of records and staff interview, the facility fails to assure that the required fire alarm system is installed, tested and maintained in accordance with NFPA 70 and 72. The deficient practice reduces the reliability and capability of the fire alarm system to function, affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/10, between 2:00 p.m. and 6:00 p.m., a review of the facility's annual fire alarm report dated 04/26/10, revealed multiple deficiencies, including but not limited to:

-- 1. Only one duct detector out of six is functioning; five duct detectors are not connected.
-- 2. Six smoke detectors located in the Activity Center are not working; wrong type and need to be switched out.
-- 3. No duct detector for Air Handling Unit #4.

Staff A and B were present and acknowledged the deficiencies. Staff A and B stated they had made several corrections, but were waiting on the vendor to complete repairs. The facility's staff implemented a Fire Watch on 05/19/10 and contacted the alarm company. An alarm company technician arrive on site prior to the completion of the survey.

Based upon observation and staff interview, the facility fails to assure that the automatic sprinkler system is continuously maintained in accordance with NFPA 13 and NFPA 25. This deficient practice reduces the reliability of the sprinkler system to function as designed, affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/10, between 2:00 p.m. and 6:00 p.m., it is observed that multiple sprinkler heads located in the facility's attic area are in physical contact with insulation.

Staff A and B were present and acknowledged that the sprinkler heads are in contact with the insulation. Staff A stated that the insulation was installed post sprinkler installation.

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice could prevent the full instant use of the egress pathway, affecting 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/2010, between 2:00 p.m. and 6:00 p.m., it is observed that plants and miscellaneous pieces of furniture are stored at the East exit from the activity center.

Staff A and B were present and acknowledged the presence of the stored items. Staff C immediately removed the items from the area.

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. The deficient practice increases the risk of an electrical fire and smoke, affecting 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/2010, between 2:00 p.m. and 6:00 p.m., it is observed that:

-- 1. Electrical outlets near the handsink in the Laboratory are not protected by a G.F.C.I. breaker.
-- 2. A drop cord was in use to power a fan in the X-ray room.

Staff A and B were present and acknowledged that outlets in a wet location should be protected by a G.F.C.I. and that extension cords are prohibited.

Based on observation and a review of documents, the facility fails to assure a proper 2 hour fire rated separation to a non-conforming building. The deficient practice compromises the fire-resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting 3 of 3 smoke zones. The facility has a capacity of 40 with a census of 36 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/2010, between 2:00 p.m. and 6:00 p.m., unsealed gaps around wires, pipes and conduit were observed in designated 2-hour rated walls near the Pharmacy and near the Diet Kitchen.

Staff A and B were present, aware of the findings, and acknowledged the presence of unsealed gaps in the designated fire walls.

Based upon observation and staff interview, the facility failed to assure that hazardous areas are protected by one hour fire rated construction. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/10, between 2:00 p.m. and 6:00 p.m., it is observed that corridor doors to a storage room near the facility's boiler room are not self-closing.

Staff A and B were present and acknowledged the findings. Staff A stated that he would obtain and install closers on the doors to ensure that the doors are self-closing.

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/10, between 2:00 p.m. and 6:00 p.m., a review of records for the last 4 quarters revealed the following:

-- 1. Fire drills are conducted within close proximity of each other:
a. Fire Drills for the 2nd Shift, 2nd, 3rd, 4th Qtr 2009 and 1st Qtr 2009, were held at 6:30 a.m., 6:15 a.m., 6:15 a.m. and 5:45 a.m., respectively.

Staff A and B were present and acknowledged the results of the record review.

Based upon a review of records and staff interview, the facility fails to assure that the required fire alarm system is installed, tested and maintained in accordance with NFPA 70 and 72. The deficient practice reduces the reliability and capability of the fire alarm system to function, affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/10, between 2:00 p.m. and 6:00 p.m., a review of the facility's annual fire alarm report dated 04/26/10, revealed multiple deficiencies, including but not limited to:

-- 1. Only one duct detector out of six is functioning; five duct detectors are not connected.
-- 2. Six smoke detectors located in the Activity Center are not working; wrong type and need to be switched out.
-- 3. No duct detector for Air Handling Unit #4.

Staff A and B were present and acknowledged the deficiencies. Staff A and B stated they had made several corrections, but were waiting on the vendor to complete repairs. The facility's staff implemented a Fire Watch on 05/19/10 and contacted the alarm company. An alarm company technician arrive on site prior to the completion of the survey.

Based upon observation and staff interview, the facility fails to assure that the automatic sprinkler system is continuously maintained in accordance with NFPA 13 and NFPA 25. This deficient practice reduces the reliability of the sprinkler system to function as designed, affecting 3 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/10, between 2:00 p.m. and 6:00 p.m., it is observed that multiple sprinkler heads located in the facility's attic area are in physical contact with insulation.

Staff A and B were present and acknowledged that the sprinkler heads are in contact with the insulation. Staff A stated that the insulation was installed post sprinkler installation.

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice could prevent the full instant use of the egress pathway, affecting 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/2010, between 2:00 p.m. and 6:00 p.m., it is observed that plants and miscellaneous pieces of furniture are stored at the East exit from the activity center.

Staff A and B were present and acknowledged the presence of the stored items. Staff C immediately removed the items from the area.

Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. The deficient practice increases the risk of an electrical fire and smoke, affecting 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 17 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 05/18/2010, between 2:00 p.m. and 6:00 p.m., it is observed that:

-- 1. Electrical outlets near the handsink in the Laboratory are not protected by a G.F.C.I. breaker.
-- 2. A drop cord was in use to power a fan in the X-ray room.

Staff A and B were present and acknowledged that outlets in a wet location should be protected by a G.F.C.I. and that extension cords are prohibited.