HospitalInspections.org

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two of the fourteen smoke compartments in the building. The facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and staff interview on 10/13/11, revealed the Physical Therapy Smoke Door was not equipped with a self-closing device. Maintenance Staff confirmed these observations during the survey process.

Based upon observation, record review and interview, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 9.

Findings include:

Observation, record review and staff interview 10/13/11, the facility fire drill documentation showed that all the drills for all shifts were held within the same hour for all four quarters. Maintenance Staff verified the documentation during the survey process.

(A)
Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 9.

Findings include:

Observation and interview on 10/13/11, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical panel was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice. Maintenance Staff verified this observation at the time of the survey.

(B)
Based on observation and interview, the facility failed to provided a properly maintained fire alarm system. All of the facility was directly affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview on 10/13/11, revealed that the pull stations located throughout the facility were approximately 5 feet above the floor. These pull stations are required to be between 3 1/2 feet to 4 1/2 feet above the floor according to NFPA 72 2-8.1. Maintenance Staff confirmed these observations at the time of the survey process.

Based on observation and record review, the facility failed to maintain and test a complete automatic sprinkler system. All smoke compartment in building could be affected by the deficient practice and potentially affected all residents, visitors and staff. The facility has 25 certified beds and at the time of the survey the census was 9.
Findings include:
Observation and record review on 10/13/11, revealed that the sprinkler system had not had a 5 year internal inspection. The facility was unable to produce documentation that the test had been conducted. Maintenance Staff verified this observation during the survey process.

Based on observation and interview the facility could not provide documentation that the curtains, draperies and window blinds throughout the facility were flame resistant. The facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. This has the potential of affecting all the residents, staff and visitors in the facility in the event of a fire. This facility has a capacity of 25 with a census of 9.

Findings include:

Observations and staff interview of the window treatments in the 4th floor corridor on 10/13/11, revealed they were not tagged as being flame retardant. Maintenance Staff confirmed this observation and that the facility did not have documentation that the window treatments were flame resistant.

Based on observation, staff interview and record review, the facility did not assure that all the smoke dampers are operable to prevent the passage of smoke and fire to another smoke zone. This deficient practice effects all occupants in all smoke zones who may need to use these areas as a safe zone in the event of an emergency. This facility has a capacity of 25 and a census of 9 residents.

Observation, staff interview and record review on 10/13/11, revealed no documentation for the inspection of the smoke dampers throughout the facility. Maintenance Staff verified this observation 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, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 9 at the time of the survey.

Findings Include:

Observation and staff interview on 10/13/11, revealed the facility failed to provide Ground Fault Circuit Interrupter electrical outlets for the following areas: 3rd floor Dietitian's office restroom and the Cardiac rehab. Maintenance Staff verified these observations during the survey process.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected two of the fourteen smoke compartments in the building. The facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and staff interview on 10/13/11, revealed the Physical Therapy Smoke Door was not equipped with a self-closing device. Maintenance Staff confirmed these observations during the survey process.

Based upon observation, record review and interview, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 9.

Findings include:

Observation, record review and staff interview 10/13/11, the facility fire drill documentation showed that all the drills for all shifts were held within the same hour for all four quarters. Maintenance Staff verified the documentation during the survey process.

(A)
Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 9.

Findings include:

Observation and interview on 10/13/11, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the electrical panel was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice. Maintenance Staff verified this observation at the time of the survey.

(B)
Based on observation and interview, the facility failed to provided a properly maintained fire alarm system. All of the facility was directly affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview on 10/13/11, revealed that the pull stations located throughout the facility were approximately 5 feet above the floor. These pull stations are required to be between 3 1/2 feet to 4 1/2 feet above the floor according to NFPA 72 2-8.1. Maintenance Staff confirmed these observations at the time of the survey process.

Based on observation and record review, the facility failed to maintain and test a complete automatic sprinkler system. All smoke compartment in building could be affected by the deficient practice and potentially affected all residents, visitors and staff. The facility has 25 certified beds and at the time of the survey the census was 9.
Findings include:
Observation and record review on 10/13/11, revealed that the sprinkler system had not had a 5 year internal inspection. The facility was unable to produce documentation that the test had been conducted. Maintenance Staff verified this observation during the survey process.

Based on observation and interview the facility could not provide documentation that the curtains, draperies and window blinds throughout the facility were flame resistant. The facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. This has the potential of affecting all the residents, staff and visitors in the facility in the event of a fire. This facility has a capacity of 25 with a census of 9.

Findings include:

Observations and staff interview of the window treatments in the 4th floor corridor on 10/13/11, revealed they were not tagged as being flame retardant. Maintenance Staff confirmed this observation and that the facility did not have documentation that the window treatments were flame resistant.

Based on observation, staff interview and record review, the facility did not assure that all the smoke dampers are operable to prevent the passage of smoke and fire to another smoke zone. This deficient practice effects all occupants in all smoke zones who may need to use these areas as a safe zone in the event of an emergency. This facility has a capacity of 25 and a census of 9 residents.

Observation, staff interview and record review on 10/13/11, revealed no documentation for the inspection of the smoke dampers throughout the facility. Maintenance Staff verified this observation 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, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 9 at the time of the survey.

Findings Include:

Observation and staff interview on 10/13/11, revealed the facility failed to provide Ground Fault Circuit Interrupter electrical outlets for the following areas: 3rd floor Dietitian's office restroom and the Cardiac rehab. Maintenance Staff verified these observations during the survey process.