HospitalInspections.org

Based on observations, it was determined the facility was a two-story building and consisted of fire resistive construction and protected combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed. This deficient practice affects occupants in 2 of 16 zones. The facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

1. Observations on 12/21/10, revealed a gap (approximately 3 inches in size) around a conduit penetration in the corridor wall of the Mechanical Room housing the air handlers.

2. Observations on 12/21/10, revealed a hole (approximately 4 inches by 6 inches in size) above a pipe penetration in the corridor wall and another hole (approximately 1 inch by 18 inches in size) in the corridor wall of the Second Floor Electrical Room.

Based on observations, it was determined the facility was a two-story building and consisted of fire resistive construction and protected combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations were sealed. This deficient practice affects occupants in 1 of 16 zones. The facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

Observations on 12/21/10, revealed a gap (approximately 1 inch in size) around a cable penetration and another gap (approximately 1/4 inch in size) around a duct penetration in the corridor wall of the X Ray File Storage Room.

Based on observations, the facility failed to separate the corridors from other areas by partitions complying with 19.3.6.2 through 19.3.6.5 of the 2000 Life Safety Code. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Life Safety Code. This deficient practice could affect occupants in 1 of 16 zones. This facility has a capacity of a 25 and had a census of a 5.

Findings include:

Observations on 12/21/10, revealed the Employee Time Clock Room on the first floor was open to the corridor. The zone was equipped with a complete automatic sprinkler system and the corridor was provide with smoke detection. Absent was smoke detection within the room.

(A)
Based on record review, the facility failed to maintain and test smoke detectors for sensitivity in accordance with National Fire Protection Association (NFPA) 72, 7-3.2.1. Two of one hundred and sixteen smoke detectors in the building were affected by the deficient practice. The facility census is 25 with a capacity of 5.

Findings include:

Record review on 12/21/10, revealed the smoke detectors in the Oxygen Closet and the Vending Closet were not provided with a tested value on the 2/1/10 sensitivity report.

(B)
Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (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. This deficient practice affects occupants in 2 of 16 zones. This facility has a capacity of 25 and a census of 5.

Findings include:

1. Observations on 12/21/10, revealed the smoke detector in the Lab Director's Office had been installed within 36 inches of the air supply.

2. Observations on 12/21/10, revealed the smoke detector in the corridor by Room 228 had been installed within 36 inches of the air return.

Based on observations, the facility failed to install a sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice affect occupants in 1 of 16 zones. The facility has a capacity of 25 with a census of 5.

Findings include:

Observations on 12/21/10, revealed sprinkler heads had not been installed underneath the garage door in the Emergency Room Ambulance Garage.

Based on observation, record review, and staff interview, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 5.

Findings include:

1. During the record review of the facilities fire safety components on 12/21/10, revealed the annual sprinkler system inspection report and first and second quarterly inspections reports did not contain inspection of the Hydraulic Nameplate. Also the documentation of the first and second quarterly inspections failed to contain inspection of the alarm devices and testing of the waterflow switch.

2. Record review and staff interview on 12/21/10, revealed the facility was unable to provide documentation to show the standpipe system located in the first floor corridor by the Kitchen and the second floor corridor by the Outpatient Clinic had been tested or inspected. At the time of the survey Maintenance Staff A reported the standpipes had not been tested.

3. Observations on 12/21/10, revealed corrosion on the sprinkler head in the Second Floor North Housekeeping Closet.

Based on record review, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 5.

Findings include:

During the record review of the facilities fire safety components on 12/21/10, revealed the annual sprinkler system inspection report and first and second quarterly inspections reports did not contain inspection of the Hydraulic Nameplate. Also the documentation of the first and second quarterly inspections failed to contain inspection of the alarm devices and testing of the waterflow switch.

Based on observations, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. The facility kitchen area is located in one of sixteen zones in the building. The facility has 25 certified beds and at the time of the survey the facility census was 5.

Findings include:

1. Observations on 12/21/10, revealed two holes (approximately 1 inch in size) in the east and west sides of the hood in the Kitchen.

2. Observations on 12/21/10, revealed the electric grill in the Kitchen had been moved out from underneath the nozzle for the wet chemical suppression system.

Based on observations, the facility failed to inspect and test the rolling fire door to check for proper operation and full closure in accordance with National Fire Protection Association (NFPA) Standard 80, 15.2.4.3. This deficient practice affects occupants in 1 of 16 zones. The facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

Observations on 12/21/10, revealed the facility was unable to provide documentation to show the rolling fire door in the corridor wall of the Kitchen had been provided with an annual inspection.

Based on observations, the facility failed to inspect and test the rolling fire door to check for proper operation and full closure in accordance with National Fire Protection Association (NFPA) Standard 80, 15.2.4.3. This deficient practice affects occupants in 1 of 16 zones. The facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

Observations on 12/21/10, revealed the facility was unable to provide documentation to show the rolling fire door in the corridor wall of the Reception Areas for Radiology and the Lab had been provided with an annual inspection.

Based on observations, 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 occupants in 1 of 16 zones. This facility has a capacity of 25 and a census of 5.

Findings include:

Observations on 12/21/10, revealed the electrical panel door to Panel #3 did not latch properly when tested at the time of the survey.

Based on observations, it was determined the facility was a two-story building and consisted of fire resistive construction and protected combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed. This deficient practice affects occupants in 2 of 16 zones. The facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

1. Observations on 12/21/10, revealed a gap (approximately 3 inches in size) around a conduit penetration in the corridor wall of the Mechanical Room housing the air handlers.

2. Observations on 12/21/10, revealed a hole (approximately 4 inches by 6 inches in size) above a pipe penetration in the corridor wall and another hole (approximately 1 inch by 18 inches in size) in the corridor wall of the Second Floor Electrical Room.

Based on observations, it was determined the facility was a two-story building and consisted of fire resistive construction and protected combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations were sealed. This deficient practice affects occupants in 1 of 16 zones. The facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

Observations on 12/21/10, revealed a gap (approximately 1 inch in size) around a cable penetration and another gap (approximately 1/4 inch in size) around a duct penetration in the corridor wall of the X Ray File Storage Room.

Based on observations, the facility failed to separate the corridors from other areas by partitions complying with 19.3.6.2 through 19.3.6.5 of the 2000 Life Safety Code. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Life Safety Code. This deficient practice could affect occupants in 1 of 16 zones. This facility has a capacity of a 25 and had a census of a 5.

Findings include:

Observations on 12/21/10, revealed the Employee Time Clock Room on the first floor was open to the corridor. The zone was equipped with a complete automatic sprinkler system and the corridor was provide with smoke detection. Absent was smoke detection within the room.

Based upon record review, the facility failed to hold fire drills under varied conditions at different times of the day for four 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 5.

Findings include:

Record review on 12/21/10, revealed the facility fire drill documentation showed 3 of 4 of the second shift drills were conducted between 7:10 p.m. and 7:41 p.m. and 4 of 4 of the third shift drills were conducted between 5:25 a.m. and 6:00 a.m. during the last 12 months.

Based on record review, the facility failed to provide an appropriate fire alarm inspection report in accordance with the NFPA 72, 1999 edition, 7-5.2.2. A permanent record of all inspections, testing, and maintenance shall be provided that includes the information listed under 7-5.2.2 and all the applicable information requested in figure 7-5.2.2. All occupants of the facility could be affected by this deficient practice. This facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

Record review of the the fire alarm test records on 12/21/10, revealed the fire alarm systems were inspected, tested, and maintained by Per Mar Security and Feld. The inspection reports did not list the initiating and supervisory devices individually.

(A)
Based on record review, the facility failed to maintain and test smoke detectors for sensitivity in accordance with National Fire Protection Association (NFPA) 72, 7-3.2.1. Two of one hundred and sixteen smoke detectors in the building were affected by the deficient practice. The facility census is 25 with a capacity of 5.

Findings include:

Record review on 12/21/10, revealed the smoke detectors in the Oxygen Closet and the Vending Closet were not provided with a tested value on the 2/1/10 sensitivity report.

(B)
Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with National Fire Protection Association (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. This deficient practice affects occupants in 2 of 16 zones. This facility has a capacity of 25 and a census of 5.

Findings include:

1. Observations on 12/21/10, revealed the smoke detector in the Lab Director's Office had been installed within 36 inches of the air supply.

2. Observations on 12/21/10, revealed the smoke detector in the corridor by Room 228 had been installed within 36 inches of the air return.

Based on observations, the facility failed to install a sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice affect occupants in 1 of 16 zones. The facility has a capacity of 25 with a census of 5.

Findings include:

Observations on 12/21/10, revealed sprinkler heads had not been installed underneath the garage door in the Emergency Room Ambulance Garage.

Based on observation, record review, and staff interview, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 5.

Findings include:

1. During the record review of the facilities fire safety components on 12/21/10, revealed the annual sprinkler system inspection report and first and second quarterly inspections reports did not contain inspection of the Hydraulic Nameplate. Also the documentation of the first and second quarterly inspections failed to contain inspection of the alarm devices and testing of the waterflow switch.

2. Record review and staff interview on 12/21/10, revealed the facility was unable to provide documentation to show the standpipe system located in the first floor corridor by the Kitchen and the second floor corridor by the Outpatient Clinic had been tested or inspected. At the time of the survey Maintenance Staff A reported the standpipes had not been tested.

3. Observations on 12/21/10, revealed corrosion on the sprinkler head in the Second Floor North Housekeeping Closet.

Based on record review, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 5.

Findings include:

During the record review of the facilities fire safety components on 12/21/10, revealed the annual sprinkler system inspection report and first and second quarterly inspections reports did not contain inspection of the Hydraulic Nameplate. Also the documentation of the first and second quarterly inspections failed to contain inspection of the alarm devices and testing of the waterflow switch.

Based on observations, the facility failed to provide a commercial cooking suppression system that is tested and maintained as required. The facility kitchen area is located in one of sixteen zones in the building. The facility has 25 certified beds and at the time of the survey the facility census was 5.

Findings include:

1. Observations on 12/21/10, revealed two holes (approximately 1 inch in size) in the east and west sides of the hood in the Kitchen.

2. Observations on 12/21/10, revealed the electric grill in the Kitchen had been moved out from underneath the nozzle for the wet chemical suppression system.

Based on observations, the facility failed to inspect and test the rolling fire door to check for proper operation and full closure in accordance with National Fire Protection Association (NFPA) Standard 80, 15.2.4.3. This deficient practice affects occupants in 1 of 16 zones. The facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

Observations on 12/21/10, revealed the facility was unable to provide documentation to show the rolling fire door in the corridor wall of the Kitchen had been provided with an annual inspection.

Based on observations, the facility failed to inspect and test the rolling fire door to check for proper operation and full closure in accordance with National Fire Protection Association (NFPA) Standard 80, 15.2.4.3. This deficient practice affects occupants in 1 of 16 zones. The facility has a capacity of 25 and at the time of the survey had a census of 5.

Findings include:

Observations on 12/21/10, revealed the facility was unable to provide documentation to show the rolling fire door in the corridor wall of the Reception Areas for Radiology and the Lab had been provided with an annual inspection.

Based on observations, 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 occupants in 1 of 16 zones. This facility has a capacity of 25 and a census of 5.

Findings include:

Observations on 12/21/10, revealed the electrical panel door to Panel #3 did not latch properly when tested at the time of the survey.