HospitalInspections.org

Based on record review and staff interview, the facility failed to test and maintain the emergency lighting system in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 7.9 and 19.2.9.1. A monthly test of the system for 30 seconds shall be conducted. A yearly test of the system for 90 minutes shall be conducted. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 0 residents.

Findings include:

Record review and staff interview on 11/22/24 at 8:59 a.m., revealed that the above facility was missing the September 2024 and October 2024 weekly 30 second testing of the emergency lighting system.
Maintenance Director verified this finding during the interview.

Based on record review and staff interview, the facility failed to inspect and service the Kitchen Hood and Duct Extinguishment System in accordance with National Fire Protection Association, NFPA 96, 2011 edition. The deficient practice affects facility staff in one out of seven smoke zones which includes Dining Room. The facility has a capacity of 25 with a census of 0 residents.

Findings include:

During the survey on 11/19/24 at 10:45 a.m. while the self-igniting burners on the commercial stove were tested, it was revealed that two of burners in the back right side and one of the front left burners would not automatically ignite. This increases the risk that the burner could inadvertently be left on would continue to release gas into the room. Staff interviewed stated that she didn't know why it wasn't lighting and stated that it doesn't always work properly.

Maintenance Director verified this finding during the survey.

Based on observation and interview, the facility failed to install, test, and maintain the fire alarm system within the building in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code and Signaling Code, 2010 edition. This deficient practice could affect all occupants within the facility. The facility had a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

Observation and interview on 11/19/24 at 10:45 a.m., revealed the facility failed to maintain the fire alarm system in the Medical gas storage room. This room contained a smoke detector that was not securely fastened to the ceiling and was hanging by wires.

The Maintenance Director confirmed this observation at the time of the survey.

Based on record review, observations and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 0 clients.

Findings include:

Observation and interview on 11/19/24 at 10:50 a.m. revealed a missing sprinkler e-ring cover on the sprinkler head in the storage room known as "EVS" storage room.

Maintenance Director verified this observation during the survey process.

Based on observation and interview, the facility did not ensure corridor doors were smoke resisting to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.1/19.3.6.1 and 18.3.6.3/19.3.6.3. This deficient practice affected one of eight smoke compartments. This facility had a capacity of 25 and a census of 0 residents at the time of the survey.

Findings include:

Observation and interview on 11/22/24 at 11:19 a.m., revealed an approximate 1/4 inch hole located above the door handle on the CT Control Room door due to the handle being coming away from the door and falling off.

The Maintenance Director confirmed this finding at the time of the survey.

Based on observation and interview, the facility is not assuring that two of two smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.7.3 and allow the passage of smoke and fire to another smoke zone. It was determined the facility failed to maintain the 30 minute fire resistive rating of the smoke barrier. This deficient practice affects all residents, staff, and visitors in all smoke zones. The facility has a capacity of 25 with a census of 0.

Findings include:

1. Observations and interview on 11/19/24 at 11:00 a.m., revealed ceiling paneling located in the Exam #1 in the restroom was missing.

2. Observations and interview on 11/19/24 at 11:16 a.m., revealed in the room labeled X-ray #1 had a two to three inch gap between the wall and ceiling panel were a number of pipes are running up the wall into the top of the ceiling into the ceiling panels.

The Maintenance Director verified these observations during the survey process.

Based on observation and testing, the facility did not ensure fire rated smoke barriers doors were maintained and positive latching in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 8.3.3.1 and 4.6.12.3 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition. This deficient practice affected all smoke zones in the facility. This facility had a capacity of 25 and a census of 0 patients at the time of the survey.

Findings include:

Observation and testing on 11/19/24 at approximately 10:47 a.m., revealed the all of the double smoke barrier doors between the Kitchen and Emergency room hallway could not fully close and was dragging on the floor. It was also observed that the double smoke barrier doors had at least a 1/4 inch gap between the two doors when it was forced closed.

The Mainentance Director verified this finding during the interview.