HospitalInspections.org

Based on observation, building schematic review and interview, the facility failed to place a two hour fire barrier between the main building and the residential building. This has the potential to affect all patients, staff, and visitors in the facility. The facility's census was 27 patients.

Findings include:

On 07/23/14 at 10:45 A.M. observation of the area between the building and the residential care addition failed to reveal the rating of the wall in the corridor. Review of the schematic did not reveal it to be rated.

On 07/23/14 at 10:45 A.M. in an interview, Staff OO said he/she thought the architect missed placing a two hour wall in the corridor.

On 07/22/14 at 11:54 A.M. in an interview, Staff OO said the architects had written the section of the wall in the corridor needs to be two hours rated.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings resisted the passage of smoke. This has the potential to affect all patients, staff, and visitors in the facility. The facility's census was 27 patients.

Findings include:

On 07/22/14 at 11:15 A.M. the door to storage room C112 was observed to have a gap of one eighth of an inch above and below the lock that would not resist the passage of smoke.

On 07/22/14 at 11:15 A.M. in an interview, Staff OO confirmed the observation.

Based on observation and interview, the facility failed to ensure each path of egress with a not-readily-apparent-exit, had exit signage in the path of egress. This has the potential to affect all patients, staff, and visitors in the facility. The facility's census was 27 patients.

Findings include:

1. On 07/22/14 at 9:00 A.M. the outpatient reception waiting area was observed to have two doors. The waiting area was observed to have an evacuation plan that directed individuals to egress through a door next to the office window. An exit sign was not observed to direct individuals to egress through this door.

On 07/22/14 at 9:00 A.M. in an interview, Staff OO confirmed the observation.

2. On 07/22/14 at 2:30 P.M. a tour was taken of the enclosed courtyard for use by the adult south unit. Observation revealed once in the courtyard, there wasn't an exit sign to direct patients to a path of egress.

On 07/22/14 at 2:30 P.M. in an interview, Staff OO confirmed the observation.

3. On 07/22/14 at 10:15 A.M. the path of egress from the adult north unit was observed to discharge to a paved area where an iron fence was observed immediately upon discharge. The iron fence did not have an exit sign directing egress in the event of an emergency.

On 07/22/14 at 10:15 A.M. in an interview, Staff OO said patients, staff and visitors are to turn left.

Based on observation, schematic review and interview, the facility failed to maintain the fire ratings of its barriers. This has the potential to affect all patients, staff, and visitors in the facility. The facility's census was 27 patients.

Findings include:

On 07/21/14 at 1:35 P.M. a tour was conducted of the facility with Staff OO.

1. On 07/22/14 at 1:46 P.M. the double doors leading to the lobby was observed to have a gap of greater than an eighth of an inch between them. Review of the schematic revealed the doors were located within a smoke barrier.

On 07/22/14 at 1:46 P.M. in an interview, Staff OO confirmed the observation.

2. On 07/21/14 at 2:15 P.M. a one inch open conduit was observed above the drop down ceiling at the southern 90 degree angle formed by the double doors and the two hour rated wall that separated the eastern residential care wing from the main building near the dining area.

On 07/21/14 at 2:15 P.M. in an interview, Staff OO confirmed the observation.

3. On 07/21/14 at 2:22 P.M. a gap was observed in the two hour rated wall opposite the area described in #1.

On 07/21/14 at 2:22 P.M. in an interview, Staff OO confirmed the observation.

4. On 07/21/14 at 2:33 P.M. heating, ventilation and cooling duct work was observed to go through the two hour rated wall in room D122 and out into the corridor. The duct was not observed to have any kind of damper.

On 07/21/14 at 2:33 P.M. in an interview, Staff OO confirmed the observation.

5. On 07/21/14 at 2:58 P.M. observation above the drop down ceiling of the one hour wall in the kitchen/production area revealed a a two inch conduit was unsealed with blue wires coming out of it. It was observed just to the left of a sprinkler line.

On 07/21/14 at 2:58 P.M. in an interview, Staff OO confirmed the observation.

6. On 07/21/14 at 3:16 P.M. observation above the drop down ceiling of the one hour fire wall surrounding storage room A171 revealed a half inch open conduit over the doors.

On 07/21/14 at 3:16 P.M. in an interview, Staff OO confirmed the observation.

7. On 07/21/14 at 3:38 P.M. observation above the drop down ceiling of the one hour wall surrounding room A143p revealed a four inch open conduit with blue wires coming out of it, and a open one inch conduit with a green wire coming out of it.

On 07/21/14 at 3:38 P.M. in an interview, Staff OO confirmed the observation.

On 07/22/14 at 9:00 A.M. the tour of the facility resumed with Staff OO.

8. On 07/22/14 at 10:48 A.M. observation above the drop down ceiling of the one hour wall near room 149 in north patient wing revealed a one inch open conduit with grey wire and a one inch open steel flex conduit with grey wire.

On 07/22/14 at 10:48 A.M. in an interview, Staff OO confirmed the observation.

9. On 07/22/14 at 10:55 A.M. observation above the drop down ceiling of the one hour wall in the south laundry room revealed a one inch open conduit. It was observed to the right of the washing machine.

On 07/22/14 at 10:55 A.M. in an interview, Staff OO confirmed the observation.

10. On 07/22/14 at 10:59 A.M. observation of the one hour rated wall in a data closet, room C111, revealed a one inch hole between two green conduits.

On 07/22/14 at 10:59 A.M. in an interview, Staff OO confirmed the observation.

11. On 07/22/14 at 11:05 A.M. in clean utility room C109, observation above the drop down ceiling of the one hour fire rated wall revealed a one inch open conduit with blue wire coming out of it.

On 07/22/14 at 11:05 A.M. in an interview, Staff OO confirmed the observation.

12. On 07/22/14 at 11:30 A.M. observation above the drop down ceiling of the one hour rated wall in room C118 revealed two one inch holes, with one having a grey wire coming from it.

On 07/22/14 at 11:30 A.M. in an interview, Staff OO confirmed the observation.

13. On 07/22/14 at 11:45 A.M. observation above the drop down ceiling of the two hour rated wall in the tv/group room (C138) revealed a one inch open conduit with blue wires coming from it.

On 07/22/14 at 11:45 A.M. in an interview, Staff OO confirmed the observation.




31007

A tour of the ground floor was conducted on 07/22/14 the following was noted.

14. At 1:50 PM observation of the south one hour wall of room A074 was noted to have a 3/4 inch conduit, with 2 blue cables passing through, open on the end. This was confirmed by Staff NN at the time of the observation.

15. AT 1:55 PM observation of the the north one hour wall of room A075 had two 3/4 inch conduits with multiple wires passing through open on the end and a 3/4 inch conduit penetrating the wall with open annular space around the conduit. This was confirmed by Staff NN at the time of the observation.

Based on tour and staff interview the exit access door failed to release upon fire alarm activation. This has the potential to affect all patients, staff, and visitors in the facility. The facility census was 27 patients.

Findings include:

Testing of the door's releasing mechanism completed on 07/23/14 at 10:00 A.M. revealed the right side corridor exit access door across from south wing entrance did not release when the fire alarm was initiated. This was confirmed by Staff OO at the time of the observation.

Interview with Staff OO completed on 07/23/14 at 10:20 A.M. revealed the door powered down when the alarm was activated but did not release the locking mechanism.

Based on documentation review the facility failed to have fire drills held at varying times for second shift. This has the potential to affect all patients, staff, and visitors in the facility. The facility census was 27 patients.

Findings include:

Review of the fire drills conducted on second shift completed on 07/22/14 revealed fire drills with an alarm were conducted on 09/29/13 at 6:55 P.M., on 12/30/13 at 7:11 P.M., on 03/29/14 at 6:55 P.M., and on 6/29/14 at 6:49 P.M. This information was presented to Staff OO on 07/23/14 at 11:45 P.M.

Based on observation, building schematic review and interview, the facility failed to place a two hour fire barrier between the main building and the residential building. This has the potential to affect all patients, staff, and visitors in the facility. The facility's census was 27 patients.

Findings include:

On 07/23/14 at 10:45 A.M. observation of the area between the building and the residential care addition failed to reveal the rating of the wall in the corridor. Review of the schematic did not reveal it to be rated.

On 07/23/14 at 10:45 A.M. in an interview, Staff OO said he/she thought the architect missed placing a two hour wall in the corridor.

On 07/22/14 at 11:54 A.M. in an interview, Staff OO said the architects had written the section of the wall in the corridor needs to be two hours rated.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings resisted the passage of smoke. This has the potential to affect all patients, staff, and visitors in the facility. The facility's census was 27 patients.

Findings include:

On 07/22/14 at 11:15 A.M. the door to storage room C112 was observed to have a gap of one eighth of an inch above and below the lock that would not resist the passage of smoke.

On 07/22/14 at 11:15 A.M. in an interview, Staff OO confirmed the observation.

Based on observation and interview, the facility failed to ensure each path of egress with a not-readily-apparent-exit, had exit signage in the path of egress. This has the potential to affect all patients, staff, and visitors in the facility. The facility's census was 27 patients.

Findings include:

1. On 07/22/14 at 9:00 A.M. the outpatient reception waiting area was observed to have two doors. The waiting area was observed to have an evacuation plan that directed individuals to egress through a door next to the office window. An exit sign was not observed to direct individuals to egress through this door.

On 07/22/14 at 9:00 A.M. in an interview, Staff OO confirmed the observation.

2. On 07/22/14 at 2:30 P.M. a tour was taken of the enclosed courtyard for use by the adult south unit. Observation revealed once in the courtyard, there wasn't an exit sign to direct patients to a path of egress.

On 07/22/14 at 2:30 P.M. in an interview, Staff OO confirmed the observation.

3. On 07/22/14 at 10:15 A.M. the path of egress from the adult north unit was observed to discharge to a paved area where an iron fence was observed immediately upon discharge. The iron fence did not have an exit sign directing egress in the event of an emergency.

On 07/22/14 at 10:15 A.M. in an interview, Staff OO said patients, staff and visitors are to turn left.

Based on observation, schematic review and interview, the facility failed to maintain the fire ratings of its barriers. This has the potential to affect all patients, staff, and visitors in the facility. The facility's census was 27 patients.

Findings include:

On 07/21/14 at 1:35 P.M. a tour was conducted of the facility with Staff OO.

1. On 07/22/14 at 1:46 P.M. the double doors leading to the lobby was observed to have a gap of greater than an eighth of an inch between them. Review of the schematic revealed the doors were located within a smoke barrier.

On 07/22/14 at 1:46 P.M. in an interview, Staff OO confirmed the observation.

2. On 07/21/14 at 2:15 P.M. a one inch open conduit was observed above the drop down ceiling at the southern 90 degree angle formed by the double doors and the two hour rated wall that separated the eastern residential care wing from the main building near the dining area.

On 07/21/14 at 2:15 P.M. in an interview, Staff OO confirmed the observation.

3. On 07/21/14 at 2:22 P.M. a gap was observed in the two hour rated wall opposite the area described in #1.

On 07/21/14 at 2:22 P.M. in an interview, Staff OO confirmed the observation.

4. On 07/21/14 at 2:33 P.M. heating, ventilation and cooling duct work was observed to go through the two hour rated wall in room D122 and out into the corridor. The duct was not observed to have any kind of damper.

On 07/21/14 at 2:33 P.M. in an interview, Staff OO confirmed the observation.

5. On 07/21/14 at 2:58 P.M. observation above the drop down ceiling of the one hour wall in the kitchen/production area revealed a a two inch conduit was unsealed with blue wires coming out of it. It was observed just to the left of a sprinkler line.

On 07/21/14 at 2:58 P.M. in an interview, Staff OO confirmed the observation.

6. On 07/21/14 at 3:16 P.M. observation above the drop down ceiling of the one hour fire wall surrounding storage room A171 revealed a half inch open conduit over the doors.

On 07/21/14 at 3:16 P.M. in an interview, Staff OO confirmed the observation.

7. On 07/21/14 at 3:38 P.M. observation above the drop down ceiling of the one hour wall surrounding room A143p revealed a four inch open conduit with blue wires coming out of it, and a open one inch conduit with a green wire coming out of it.

On 07/21/14 at 3:38 P.M. in an interview, Staff OO confirmed the observation.

On 07/22/14 at 9:00 A.M. the tour of the facility resumed with Staff OO.

8. On 07/22/14 at 10:48 A.M. observation above the drop down ceiling of the one hour wall near room 149 in north patient wing revealed a one inch open conduit with grey wire and a one inch open steel flex conduit with grey wire.

On 07/22/14 at 10:48 A.M. in an interview, Staff OO confirmed the observation.

9. On 07/22/14 at 10:55 A.M. observation above the drop down ceiling of the one hour wall in the south laundry room revealed a one inch open conduit. It was observed to the right of the washing machine.

On 07/22/14 at 10:55 A.M. in an interview, Staff OO confirmed the observation.

10. On 07/22/14 at 10:59 A.M. observation of the one hour rated wall in a data closet, room C111, revealed a one inch hole between two green conduits.

On 07/22/14 at 10:59 A.M. in an interview, Staff OO confirmed the observation.

11. On 07/22/14 at 11:05 A.M. in clean utility room C109, observation above the drop down ceiling of the one hour fire rated wall revealed a one inch open conduit with blue wire coming out of it.

On 07/22/14 at 11:05 A.M. in an interview, Staff OO confirmed the observation.

12. On 07/22/14 at 11:30 A.M. observation above the drop down ceiling of the one hour rated wall in room C118 revealed two one inch holes, with one having a grey wire coming from it.

On 07/22/14 at 11:30 A.M. in an interview, Staff OO confirmed the observation.

13. On 07/22/14 at 11:45 A.M. observation above the drop down ceiling of the two hour rated wall in the tv/group room (C138) revealed a one inch open conduit with blue wires coming from it.

On 07/22/14 at 11:45 A.M. in an interview, Staff OO confirmed the observation.




31007

A tour of the ground floor was conducted on 07/22/14 the following was noted.

14. At 1:50 PM observation of the south one hour wall of room A074 was noted to have a 3/4 inch conduit, with 2 blue cables passing through, open on the end. This was confirmed by Staff NN at the time of the observation.

15. AT 1:55 PM observation of the the north one hour wall of room A075 had two 3/4 inch conduits with multiple wires passing through open on the end and a 3/4 inch conduit penetrating the wall with open annular space around the conduit. This was confirmed by Staff NN at the time of the observation.

Based on tour and staff interview the exit access door failed to release upon fire alarm activation. This has the potential to affect all patients, staff, and visitors in the facility. The facility census was 27 patients.

Findings include:

Testing of the door's releasing mechanism completed on 07/23/14 at 10:00 A.M. revealed the right side corridor exit access door across from south wing entrance did not release when the fire alarm was initiated. This was confirmed by Staff OO at the time of the observation.

Interview with Staff OO completed on 07/23/14 at 10:20 A.M. revealed the door powered down when the alarm was activated but did not release the locking mechanism.

Based on documentation review the facility failed to have fire drills held at varying times for second shift. This has the potential to affect all patients, staff, and visitors in the facility. The facility census was 27 patients.

Findings include:

Review of the fire drills conducted on second shift completed on 07/22/14 revealed fire drills with an alarm were conducted on 09/29/13 at 6:55 P.M., on 12/30/13 at 7:11 P.M., on 03/29/14 at 6:55 P.M., and on 6/29/14 at 6:49 P.M. This information was presented to Staff OO on 07/23/14 at 11:45 P.M.