HospitalInspections.org

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of eleven smoke compartments in the building. This could affect all staff in this smoke compartment. The facility has a capacity of 81 and a census of 18.

Findings include:

1. Observations on 03/16/11 at 11:29 a.m., revealed the facility failed to separate the Medical Records Storage Room from other compartments. This room contained combustible storage, was over four hundred square feet and did not have a self closing device.

2. Observations on 03/16/11 at 11:30 a.m., revealed the facility failed to separate the Medical Records Storage Room from other compartments. This room contained a 1/4 inch gap around two white wires penetrating the corridor wall above the door. The Safety Director verified these observations.

Based on observation and record review, the facility failed to document the emergency egress lighting annually. This deficient practice affects 11 of 11 smoke compartments and all patients, staff, visitors in the facility. This facility has a capacity of 81 and a census of 18.

Findings include:

1. Observations and record review on 03/16/11 at 10:15 a.m., revealed no documentation regarding the 90 minute testing of the emergency battery lighting system. The Safety Director verified this observation and stated they were in the process of implementing this annual test.

2. Observations on 03/17/11 at 4:01 p.m., revealed the facility failed to maintain the battery back-up emergency light in the Deer Creek Clinic Physical Therapy Room. This light failed to illuminate while being tested. Maintenance Staff A verified this observation.

Based on observation, the facility failed to maintain a directional exit sign at the end of the corridor for one of nine exits. This deficient practice affects approximately 3 patients, staff and visitors on the third floor of the Administrative Arts Building. The facility has a capacity of 81 and a census of 18.

Findings include:

Observations on 03/16/11 at 1:50 p.m., revealed the facility failed to maintain a directional exit sign in the third floor corridor near the Physicians Offices. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Safety Director verified this observation.

Based on observation, 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 patients. This facility has a capacity of 81 with a census of 18.

Findings include:

Observations on 03/17/11 at 4:15 p.m., revealed the facility failed to provide a properly maintained fire alarm system. Fire alarm breaker #30 located along the south wall of the Mechanical Room was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by this deficient practice. Maintenance Staff A verified this observation.

Based on observation, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect all staff in this smoke compartment. The facility has a capacity of 81 and a census of 18.

Findings include:

1. Observations on 03/16/11 at 11:32 a.m., revealed the facility failed to maintain the Fire Alarm System in the Tunnel to the Storage Garage. This corridor contained a smoke detector with in three feet of a air diffuser.

2. Observations on 03/16/11 at 11:50 a.m., revealed the facility failed to maintain the Fire Alarm System in the Pharmacy. This room contained a smoke detector with in three feet of a air diffuser.

3. Observations on 03/16/11 at 1:45 p.m., revealed the facility failed to maintain the Fire Alarm System in the Administrative Arts third floor admitting area. This corridor contained a smoke detector with in three feet of a air diffuser.

4. Observations on 03/16/11 at 1:51 p.m., revealed the facility failed to maintain the Fire Alarm System in the Administrative Arts old Chemotherapy Room. This room contained a smoke detector with in three feet of a air diffuser. The Safety Director verified these observations.

(A)
The facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. These items could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 81 and a census of 18.

Findings include:

1. Observations on 03/16/11 at 2:00 p.m., revealed the facility failed to maintain the sprinkler system in the Administrative Arts third floor Records Room. Six of twelve sprinkler heads were completely covered in lint and dust.

2. Observations on 03/16/11 at 12:43 p.m., revealed the facility failed to maintain the sprinkler system in the Occupational Therapy Office. This room contained one of one sprinkler heads missing an escutcheon ring.

3. Observations on 03/16/11 at 12:06 p.m., revealed the facility failed to maintain the sprinkler system in the Physical Therapy Corridor. Two of five sprinkler heads were completely covered in lint and dust. The Safety Director verified these observations.

(B)
Based on observation, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. Standard for the installation of Sprinkler Systems, 1999 edition, placing all residents, staff and visitors at risk in the event of a fire. The facility has a capacity of 81 and a census of 18.

1. Observations on 03/16/11 at 12:04 p.m., revealed the facility failed to maintain the sprinkler system in the Physical Therapy Room #7. One of one sprinkler heads did not contain an escutcheon ring.

2. Observations on 03/16/11 at 12:03 p.m., revealed the facility failed to provide sprinkler coverage throughout the premises. The Kitchen did not contain any sprinkler system coverage.

3. Observations on 03/16/11 at 12:02 p.m., revealed the facility failed to provide sprinkler coverage throughout the premises. The Walk in Freezer did not contain any sprinkler system coverage.

4. Observations on 03/16/11 at 12:01 p.m., revealed the facility failed to provide sprinkler coverage throughout the premises. The Kitchen Dry Storage Room did not contain any sprinkler system coverage.

5. Observations on 03/16/11 at 12:00 p.m., revealed the facility failed to provide sprinkler coverage throughout the premises. The corridor outside of Kitchen did not contain any sprinkler system coverage. The Safety Director verified these observations and stated that he was not aware these areas of the Hospital did not contain a sprinkler system coverage.

6. Observations on 03/16/11 at 11:45 a.m., revealed the facility is not providing sprinkler protection for all habitable areas and corridors. The facility failed to provide sprinkler coverage in the Team Steps Room.

Based on record review, the facility failed to maintain and test a complete automatic sprinkler system. This deficient practice effects all smoke compartments in the facility along with all residents, staff and visitors. The facility has a capacity of 81 and a census of 18.

Findings include:

Record review of the facilities fire safety components on 03/16/2011 at 10:20 a.m., revealed that the facility failed to maintain the sprinkler system. The facility could not provide documentation for the quarterly inspection for second quarter of 2010. The Safety Director verified this observation.

Based on observation the facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all staff in this room. This facility has a capacity of 81 and a census of 18.

Findings include:

1. Observations of the brown wicker blinds in the Dietary Office on 03/16/11 at 12:02 p.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the wicker blinds were flame retardant.

2. Observations of the mini blinds in the Risk Management Office on 03/16/11 at 12:40 p.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Safety Director verified these observations.

Based on observations, the facility failed to maintain emergency task illumination at the emergency generator and transfer switch location. The emergency generator would affect all smoke compartments, residents, staff and visitors. The facility has a capacity of 81 and a census was 18.

Findings include:

Observations on 03/16/11 at 11:25 a.m., revealed the facility failed to provide battery back-up emergency task illumination lighting at the Generator and transfer switch location. The Safety Director verified this observation.

Based on observation, 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 all Staff in these rooms at risk in the event of a fire. The facility had a capacity of 81 and a census of 18.

Findings Include:

1. Observations on 03/16/11 at 11:55 a.m., revealed the facility failed to maintain the electrical system in the Volunteer Room. This room contained a three way adapter supplying electrical power to a printer along the south wall. The Maintenance Director verified this observation and removed this device at the time of inspection.

2. Observations on 03/16/11 at 12:45 p.m., revealed the facility failed to maintain the electrical system in the Pool Filter Room. This room contained an open junction box with exposed electrical wiring along the west wall.

3. Observations on 03/16/11 at 1:35 p.m., revealed the facility failed to maintain the electrical system in the Administrative Arts Mechanical Room. This room contained an open junction box with exposed electrical wiring along the south wall. The Safety Director verified these observations.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of eleven smoke compartments in the building. This could affect all staff in this smoke compartment. The facility has a capacity of 81 and a census of 18.

Findings include:

1. Observations on 03/16/11 at 11:29 a.m., revealed the facility failed to separate the Medical Records Storage Room from other compartments. This room contained combustible storage, was over four hundred square feet and did not have a self closing device.

2. Observations on 03/16/11 at 11:30 a.m., revealed the facility failed to separate the Medical Records Storage Room from other compartments. This room contained a 1/4 inch gap around two white wires penetrating the corridor wall above the door. The Safety Director verified these observations.

Based on observation and record review, the facility failed to document the emergency egress lighting annually. This deficient practice affects 11 of 11 smoke compartments and all patients, staff, visitors in the facility. This facility has a capacity of 81 and a census of 18.

Findings include:

1. Observations and record review on 03/16/11 at 10:15 a.m., revealed no documentation regarding the 90 minute testing of the emergency battery lighting system. The Safety Director verified this observation and stated they were in the process of implementing this annual test.

2. Observations on 03/17/11 at 4:01 p.m., revealed the facility failed to maintain the battery back-up emergency light in the Deer Creek Clinic Physical Therapy Room. This light failed to illuminate while being tested. Maintenance Staff A verified this observation.

Based on observation, the facility failed to maintain a directional exit sign at the end of the corridor for one of nine exits. This deficient practice affects approximately 3 patients, staff and visitors on the third floor of the Administrative Arts Building. The facility has a capacity of 81 and a census of 18.

Findings include:

Observations on 03/16/11 at 1:50 p.m., revealed the facility failed to maintain a directional exit sign in the third floor corridor near the Physicians Offices. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Safety Director verified this observation.

Based on observation, 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 patients. This facility has a capacity of 81 with a census of 18.

Findings include:

Observations on 03/17/11 at 4:15 p.m., revealed the facility failed to provide a properly maintained fire alarm system. Fire alarm breaker #30 located along the south wall of the Mechanical Room was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by this deficient practice. Maintenance Staff A verified this observation.

Based on observation, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect all staff in this smoke compartment. The facility has a capacity of 81 and a census of 18.

Findings include:

1. Observations on 03/16/11 at 11:32 a.m., revealed the facility failed to maintain the Fire Alarm System in the Tunnel to the Storage Garage. This corridor contained a smoke detector with in three feet of a air diffuser.

2. Observations on 03/16/11 at 11:50 a.m., revealed the facility failed to maintain the Fire Alarm System in the Pharmacy. This room contained a smoke detector with in three feet of a air diffuser.

3. Observations on 03/16/11 at 1:45 p.m., revealed the facility failed to maintain the Fire Alarm System in the Administrative Arts third floor admitting area. This corridor contained a smoke detector with in three feet of a air diffuser.

4. Observations on 03/16/11 at 1:51 p.m., revealed the facility failed to maintain the Fire Alarm System in the Administrative Arts old Chemotherapy Room. This room contained a smoke detector with in three feet of a air diffuser. The Safety Director verified these observations.

(A)
The facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. These items could effect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all occupants in this facility with a capacity of 81 and a census of 18.

Findings include:

1. Observations on 03/16/11 at 2:00 p.m., revealed the facility failed to maintain the sprinkler system in the Administrative Arts third floor Records Room. Six of twelve sprinkler heads were completely covered in lint and dust.

2. Observations on 03/16/11 at 12:43 p.m., revealed the facility failed to maintain the sprinkler system in the Occupational Therapy Office. This room contained one of one sprinkler heads missing an escutcheon ring.

3. Observations on 03/16/11 at 12:06 p.m., revealed the facility failed to maintain the sprinkler system in the Physical Therapy Corridor. Two of five sprinkler heads were completely covered in lint and dust. The Safety Director verified these observations.

(B)
Based on observation, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. Standard for the installation of Sprinkler Systems, 1999 edition, placing all residents, staff and visitors at risk in the event of a fire. The facility has a capacity of 81 and a census of 18.

1. Observations on 03/16/11 at 12:04 p.m., revealed the facility failed to maintain the sprinkler system in the Physical Therapy Room #7. One of one sprinkler heads did not contain an escutcheon ring.

2. Observations on 03/16/11 at 12:03 p.m., revealed the facility failed to provide sprinkler coverage throughout the premises. The Kitchen did not contain any sprinkler system coverage.

3. Observations on 03/16/11 at 12:02 p.m., revealed the facility failed to provide sprinkler coverage throughout the premises. The Walk in Freezer did not contain any sprinkler system coverage.

4. Observations on 03/16/11 at 12:01 p.m., revealed the facility failed to provide sprinkler coverage throughout the premises. The Kitchen Dry Storage Room did not contain any sprinkler system coverage.

5. Observations on 03/16/11 at 12:00 p.m., revealed the facility failed to provide sprinkler coverage throughout the premises. The corridor outside of Kitchen did not contain any sprinkler system coverage. The Safety Director verified these observations and stated that he was not aware these areas of the Hospital did not contain a sprinkler system coverage.

6. Observations on 03/16/11 at 11:45 a.m., revealed the facility is not providing sprinkler protection for all habitable areas and corridors. The facility failed to provide sprinkler coverage in the Team Steps Room.

Based on record review, the facility failed to maintain and test a complete automatic sprinkler system. This deficient practice effects all smoke compartments in the facility along with all residents, staff and visitors. The facility has a capacity of 81 and a census of 18.

Findings include:

Record review of the facilities fire safety components on 03/16/2011 at 10:20 a.m., revealed that the facility failed to maintain the sprinkler system. The facility could not provide documentation for the quarterly inspection for second quarter of 2010. The Safety Director verified this observation.

Based on observation the facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all staff in this room. This facility has a capacity of 81 and a census of 18.

Findings include:

1. Observations of the brown wicker blinds in the Dietary Office on 03/16/11 at 12:02 p.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the wicker blinds were flame retardant.

2. Observations of the mini blinds in the Risk Management Office on 03/16/11 at 12:40 p.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Safety Director verified these observations.

Based on observations, the facility failed to maintain emergency task illumination at the emergency generator and transfer switch location. The emergency generator would affect all smoke compartments, residents, staff and visitors. The facility has a capacity of 81 and a census was 18.

Findings include:

Observations on 03/16/11 at 11:25 a.m., revealed the facility failed to provide battery back-up emergency task illumination lighting at the Generator and transfer switch location. The Safety Director verified this observation.

Based on observation, 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 all Staff in these rooms at risk in the event of a fire. The facility had a capacity of 81 and a census of 18.

Findings Include:

1. Observations on 03/16/11 at 11:55 a.m., revealed the facility failed to maintain the electrical system in the Volunteer Room. This room contained a three way adapter supplying electrical power to a printer along the south wall. The Maintenance Director verified this observation and removed this device at the time of inspection.

2. Observations on 03/16/11 at 12:45 p.m., revealed the facility failed to maintain the electrical system in the Pool Filter Room. This room contained an open junction box with exposed electrical wiring along the west wall.

3. Observations on 03/16/11 at 1:35 p.m., revealed the facility failed to maintain the electrical system in the Administrative Arts Mechanical Room. This room contained an open junction box with exposed electrical wiring along the south wall. The Safety Director verified these observations.