HospitalInspections.org

Based on observations and staff interview, the facility is not ensuring that doors to rooms 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 2 out of 5 smoke zones as the doors would not prevent the spread of fire and smoke. One of the deficiencies was located in a zone that would affect 4 out of 6 patients. The facility has a capacity of 25 with a census of 6.

Findings include:

1. Observation and staff interview on 9/22/11 at 12:39 p.m., revealed that the door to the Housekeeping Closet by the Kitchen was being held open with a door wedge.

2. Observation and staff interview on 9/22/11 at 12:46 p.m., revealed that the corridor door to the Dining Room was being held open by a feature of the automatic closure device attached to the door. The closure device is not connected to the facility's fire alarm system to enable the door to close upon activation of the system.

3. Observation and staff interview on 9/22/11 at 1:35 p.m., revealed that the door to the Gas Bottle Storage Room did not close and latch. The door is equipped with an automatic closure device.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, this facility failed to maintain smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects 2 out of 5 zones, including 4 out of 6 patients. This facility has a capacity of 25 and a census of 6.

Findings include:

Observation and staff interview on 9/22/11 at 1:50 p.m., revealed a penetration , (approximately 3/16 inch), around a cord line passing through the South Hall Smoke Barrier Wall. Maintenance Staff A verified observations during the survey process.

Based on record review, observations and staff interview, the facility failed to properly test and maintain the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. This deficient practice affects all occupants of the facility. This facility has a capacity of 25 and a census of 6.

Findings include:

1. Record review and staff interview on 9/22/11 at 10:10 a.m., revealed that the facility is not testing each emergency lighting system at 30 day intervals for not less than 30 seconds and is not conducting annual tests on the system for not less than 1 1/2 hours. Interview with Maintenance Staff A revealed that the facility was not aware of the standard. Maintenance Staff A verified record review during the survey process.

2. Observation and staff interview on 9/22/11 at 12:22 p.m., revealed that the emergency lighting unit located at the west exit of the Boiler Room did not illuminate when tested. The unit is also connected to an illuminated exit sign. The battery backup system for the exit sign failed when tested. Maintenance Staff A verified observations during the survey process.

3. Observation and staff interview on 9/22/11 at 12:34 p.m., revealed that the emergency lighting unit located at the south exit of the Boiler Room did not illuminate when tested. The unit is also connected to an illuminated exit sign. The battery backup system for the exit sign failed when tested. Maintenance Staff A verified observations during the survey process.

4. Observation and staff interview on 9/22/11 at 12:36 p.m., revealed that the emergency light unit for the generator transfer switch did not illuminate when tested. Maintenance Staff A verified observations during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills for two of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 25 with a census of 6.

Findings include:

Record review and staff interview on 9/22/11 at 10:39 a.m., revealed that fire drills were not documented for the 4th Quarter of 2010 on 2nd Shift and for the 2nd Quarter of 2011 on 2nd Shift. Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview the facility failed to properly protect the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 6.

Findings include:

1. Observation and staff interview on 9/22/11 at 12:26 p.m., revealed that the circuit breaker for the fire alarm system was not mechanically protected. The breaker is labeled on the main fire alarm panel. Maintenance Staff A verified observations during the survey process.

2. Observation and staff interview on 9/22/11 at 2:15 p.m., revealed that the fire alarm system did not send a trouble alarm indicating a phone line failure to a location that is monitored on a 24 hour basis. The dialer and main fire alarm panel are located in the boiler room which is not monitored 24 hours a day. Loss of the phone line sent a trouble signal to this location but did not send a trouble signal to the annunciator panel at the nurses station. Maintenance Staff A verified observations during the survey process.

Based on record review and interview with facility staff, the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition. This deficient practice affects the entire facility, including all patients and staff and visitors. The facility has 25 licensed beds and at the time of the survey the census was 6.

Findings include:

Record review and interview with facility staff on 9/22/11 at 11:15 a.m., revealed that the facility did not have documentation of smoke detector sensitivity testing. Available fire alarm inspection reports did not show specific manufacturer settings or measured settings for the smoke detectors. Maintenance Staff A stated that the company that inspects the facility's fire alarm system indicated that they were not aware of the requirement.

Based on observation and staff interview, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition, 5-6.5.2.2 and table 5-6.5.1.2. This deficient practice affects facility staff in 1 out of 5 smoke zones. The facility has a capacity of 25 with a census of 6.

Findings include:

Observation and staff interview on 9/22/11 at 1:16 p.m., revealed that the facility failed to maintain clearance of 18 inches from a sprinkler head in Administrative Storage Closet #1. Boxes were being stored close to the sprinkler head. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, 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. This deficient practice affects staff and visitors in 1 out of 5 smoke zones. The facility has a capacity of 25 and a census of 6.

Findings include:

Observation and staff interview on 9/22/11 at 1:24 p.m., revealed an electrical outlet within 6 feet of a sink on the south wall of Room #14 that was not ground fault circuit protected. This room is utilized as a hospice room. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the 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 patients. This facility has a capacity of 25 with a census of 6.

Findings include:

Record review and staff interview on 9/22/11 at 10:35 a.m., revealed that the facility does not have a policy in place in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, this facility failed to ensure that the policy 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 contains all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and patients. This facility has a capacity of 25 with a census of 6.

Findings include:

Record review and staff interview on 9/22/11 at 10:35 a.m., revealed that the facility's 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 any twenty-four hour period did not contain all required information . The policy did not contain notification of the State Fire Marshal's Office as the authority having jurisdiction. The policy did not state that the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the system has been returned to service. The policy did not contain specific information on the duties of facility staff when conducting a fire watch. A designated individual, who is specially trained, will conduct an approved fire watch while the system is out of service. Maintenance Staff A verified record review during the survey process.

Based on observations and staff interview, the facility is not ensuring that doors to rooms 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 2 out of 5 smoke zones as the doors would not prevent the spread of fire and smoke. One of the deficiencies was located in a zone that would affect 4 out of 6 patients. The facility has a capacity of 25 with a census of 6.

Findings include:

1. Observation and staff interview on 9/22/11 at 12:39 p.m., revealed that the door to the Housekeeping Closet by the Kitchen was being held open with a door wedge.

2. Observation and staff interview on 9/22/11 at 12:46 p.m., revealed that the corridor door to the Dining Room was being held open by a feature of the automatic closure device attached to the door. The closure device is not connected to the facility's fire alarm system to enable the door to close upon activation of the system.

3. Observation and staff interview on 9/22/11 at 1:35 p.m., revealed that the door to the Gas Bottle Storage Room did not close and latch. The door is equipped with an automatic closure device.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, this facility failed to maintain smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects 2 out of 5 zones, including 4 out of 6 patients. This facility has a capacity of 25 and a census of 6.

Findings include:

Observation and staff interview on 9/22/11 at 1:50 p.m., revealed a penetration , (approximately 3/16 inch), around a cord line passing through the South Hall Smoke Barrier Wall. Maintenance Staff A verified observations during the survey process.

Based on record review, observations and staff interview, the facility failed to properly test and maintain the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. This deficient practice affects all occupants of the facility. This facility has a capacity of 25 and a census of 6.

Findings include:

1. Record review and staff interview on 9/22/11 at 10:10 a.m., revealed that the facility is not testing each emergency lighting system at 30 day intervals for not less than 30 seconds and is not conducting annual tests on the system for not less than 1 1/2 hours. Interview with Maintenance Staff A revealed that the facility was not aware of the standard. Maintenance Staff A verified record review during the survey process.

2. Observation and staff interview on 9/22/11 at 12:22 p.m., revealed that the emergency lighting unit located at the west exit of the Boiler Room did not illuminate when tested. The unit is also connected to an illuminated exit sign. The battery backup system for the exit sign failed when tested. Maintenance Staff A verified observations during the survey process.

3. Observation and staff interview on 9/22/11 at 12:34 p.m., revealed that the emergency lighting unit located at the south exit of the Boiler Room did not illuminate when tested. The unit is also connected to an illuminated exit sign. The battery backup system for the exit sign failed when tested. Maintenance Staff A verified observations during the survey process.

4. Observation and staff interview on 9/22/11 at 12:36 p.m., revealed that the emergency light unit for the generator transfer switch did not illuminate when tested. Maintenance Staff A verified observations during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills for two of four quarters reviewed. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 25 with a census of 6.

Findings include:

Record review and staff interview on 9/22/11 at 10:39 a.m., revealed that fire drills were not documented for the 4th Quarter of 2010 on 2nd Shift and for the 2nd Quarter of 2011 on 2nd Shift. Maintenance Staff A verified record review during the survey process.

Based on observation and staff interview the facility failed to properly protect the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 6.

Findings include:

1. Observation and staff interview on 9/22/11 at 12:26 p.m., revealed that the circuit breaker for the fire alarm system was not mechanically protected. The breaker is labeled on the main fire alarm panel. Maintenance Staff A verified observations during the survey process.

2. Observation and staff interview on 9/22/11 at 2:15 p.m., revealed that the fire alarm system did not send a trouble alarm indicating a phone line failure to a location that is monitored on a 24 hour basis. The dialer and main fire alarm panel are located in the boiler room which is not monitored 24 hours a day. Loss of the phone line sent a trouble signal to this location but did not send a trouble signal to the annunciator panel at the nurses station. Maintenance Staff A verified observations during the survey process.

Based on record review and interview with facility staff, the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition. This deficient practice affects the entire facility, including all patients and staff and visitors. The facility has 25 licensed beds and at the time of the survey the census was 6.

Findings include:

Record review and interview with facility staff on 9/22/11 at 11:15 a.m., revealed that the facility did not have documentation of smoke detector sensitivity testing. Available fire alarm inspection reports did not show specific manufacturer settings or measured settings for the smoke detectors. Maintenance Staff A stated that the company that inspects the facility's fire alarm system indicated that they were not aware of the requirement.

Based on observation and staff interview, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13, 1999 edition, 5-6.5.2.2 and table 5-6.5.1.2. This deficient practice affects facility staff in 1 out of 5 smoke zones. The facility has a capacity of 25 with a census of 6.

Findings include:

Observation and staff interview on 9/22/11 at 1:16 p.m., revealed that the facility failed to maintain clearance of 18 inches from a sprinkler head in Administrative Storage Closet #1. Boxes were being stored close to the sprinkler head. Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, 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. This deficient practice affects staff and visitors in 1 out of 5 smoke zones. The facility has a capacity of 25 and a census of 6.

Findings include:

Observation and staff interview on 9/22/11 at 1:24 p.m., revealed an electrical outlet within 6 feet of a sink on the south wall of Room #14 that was not ground fault circuit protected. This room is utilized as a hospice room. Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the 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 patients. This facility has a capacity of 25 with a census of 6.

Findings include:

Record review and staff interview on 9/22/11 at 10:35 a.m., revealed that the facility does not have a policy in place in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. Maintenance Staff A verified record review during the survey process.

Based on record review and staff interview, this facility failed to ensure that the policy 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 contains all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and patients. This facility has a capacity of 25 with a census of 6.

Findings include:

Record review and staff interview on 9/22/11 at 10:35 a.m., revealed that the facility's 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 any twenty-four hour period did not contain all required information . The policy did not contain notification of the State Fire Marshal's Office as the authority having jurisdiction. The policy did not state that the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the system has been returned to service. The policy did not contain specific information on the duties of facility staff when conducting a fire watch. A designated individual, who is specially trained, will conduct an approved fire watch while the system is out of service. Maintenance Staff A verified record review during the survey process.