HospitalInspections.org

Based on observation and interview, the facility failed to provide separation of a hazardous area from all other areas with a corridor door with a self closer. The area of deficient practice affected one of three smoke compartments, staff and 2 residents. The facility has the capacity for 20 beds, and at the time of the survey the census was 2.

Findings are:

Observation on 05-10-11 at 10:40 a.m. revealed that the Staff Lounge did have a self closer/hold open devise installed on the corridor door that was tied to the fire alarm system to release the door. The door was propped open with waste can because the hold open devise was not working which would prevent the door to automatically close when the fire alarm sounds. Interview with Maintenance " A " on 05-10-11 at 10:40 a.m., verified the door was incorrectly held open.

Based on Observation and Interview with facility staff, the facility failed to provide independent emergency lighting in the generator location. Failure to maintain emergency lighting at the generator puts all patients, staff and visitors at risk should evacuation be necessary during a power outage. Census was 2.

Findings are:

During the survey on 05-10-11 at 10:50 A.M., observation revealed the battery operated emergency lighting unit at the generator location was not able to be tested due to a broken test button. Interview with Maintenance " A " on 05-10-11 at 10:50 A.M., verified that the light was damaged.

Based on Documentation review and Interview, the facility failed to conduct quarterly fire drills on each shift. Not conducting required fire drills puts all patients, staff and visitors at risk should a fire develop. Census was 2.

Findings are:

Documentation review on 05-10-11 at 10:00 A.M., revealed that both 12 hour shifts had not had the required fire drills. Day shift had only two drills and Night shift had only one drill in the last 12 months. Interview with Administration " A " on 05-10-11 at 10:00 A.M., confirmed the lack of required drills.

Based on Observation and interview, the facility failed to provide a remote audible annunciator for the emergency generator at a work site readily observable by staff personnel. Failure to provide the remote annunciator would affect all residents in 3 of 3 smoke zones. Resident census was 2.

Findings are:

On 05-10-11 at 09:55 A.M., observation revealed the facility had a generator and transfer switch that are in a location that is not a continuously occupied location being monitored by staff. The facility failed to provide an audible annunciator alarm at a continuously occupied location by staff. Interview With Maintenance " A " on 05-10-11 at 09:55 A.M., verified the lack of an audible annunciator although the facility is already going out for bids to fix the deficiency.

Based on observation and interview, the facility failed to provide separation of a hazardous area from all other areas with a corridor door with a self closer. The area of deficient practice affected one of three smoke compartments, staff and 2 residents. The facility has the capacity for 20 beds, and at the time of the survey the census was 2.

Findings are:

Observation on 05-10-11 at 10:40 a.m. revealed that the Staff Lounge did have a self closer/hold open devise installed on the corridor door that was tied to the fire alarm system to release the door. The door was propped open with waste can because the hold open devise was not working which would prevent the door to automatically close when the fire alarm sounds. Interview with Maintenance " A " on 05-10-11 at 10:40 a.m., verified the door was incorrectly held open.

Based on Observation and Interview with facility staff, the facility failed to provide independent emergency lighting in the generator location. Failure to maintain emergency lighting at the generator puts all patients, staff and visitors at risk should evacuation be necessary during a power outage. Census was 2.

Findings are:

During the survey on 05-10-11 at 10:50 A.M., observation revealed the battery operated emergency lighting unit at the generator location was not able to be tested due to a broken test button. Interview with Maintenance " A " on 05-10-11 at 10:50 A.M., verified that the light was damaged.

Based on Documentation review and Interview, the facility failed to conduct quarterly fire drills on each shift. Not conducting required fire drills puts all patients, staff and visitors at risk should a fire develop. Census was 2.

Findings are:

Documentation review on 05-10-11 at 10:00 A.M., revealed that both 12 hour shifts had not had the required fire drills. Day shift had only two drills and Night shift had only one drill in the last 12 months. Interview with Administration " A " on 05-10-11 at 10:00 A.M., confirmed the lack of required drills.

Based on Observation and interview, the facility failed to provide a remote audible annunciator for the emergency generator at a work site readily observable by staff personnel. Failure to provide the remote annunciator would affect all residents in 3 of 3 smoke zones. Resident census was 2.

Findings are:

On 05-10-11 at 09:55 A.M., observation revealed the facility had a generator and transfer switch that are in a location that is not a continuously occupied location being monitored by staff. The facility failed to provide an audible annunciator alarm at a continuously occupied location by staff. Interview With Maintenance " A " on 05-10-11 at 09:55 A.M., verified the lack of an audible annunciator although the facility is already going out for bids to fix the deficiency.