HospitalInspections.org

Based on observations, the facility failed to maintain the doors to 4 rooms in proper working order. This would affect approximately 6 patients and 4 staff members. The facility had a capacity of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the presence of "kick down" hold open devices on the bottom of the following doors.

1. The door to the 200 Wing Tub Room
2. The door to the C.T. Room
3. The door to the C.T. Control Room
4. The door to the O.R. Anit-Room

Maintenance Supervisor A confirmed these findings.

Based on observations, the facility failed to maintain 1 hazardous room properly separated by failing to properly maintain the doors to the room. This affects approximately 5 staff members only due to the fact that the deficiency occurred in a non-patient area (basement). The facility had a capacity of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11 revealed the 2 doors to the Laundry Room in the Basement failed to close and latch properly into the door frame when tested.

Maintenance Staff A confirmed this finding.

Based on observations, the facility failed to provide an approved exit discharge from 3 exits location in the facility. This affects all occupants within the facility. The facility had a license of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the facility failed to provide concrete or asphalt sidewalks that were at least 48 inches wide that provided exit discharge to a public sidewalk, public street or parking lot from the following exits.

1. The South Basement exit. This exit door was located below ground level. The exit discharge went up exterior of the building, ending abruptly in a grassy area.

2. The Elevator exit in the Basement. This exit door is located below ground level. The exit discharge went up exterior of the building, ending abruptly in a grassy area.

3. The exit from the O.B department.

Maintenance Supervisor A confirmed these findings.

Based on observations, the facility failed to provide proper illumination of the means of egress and exit discharge at 1 exit by not having at least 2 functioning exterior lights. This affects approximately 8 staff members only due to the fact that this deficiency occurred in a non-patient area. The facility had a capacity of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the exit discharge area from the South Basement Exit failed to be equipped with 2 light bulbs.

Maintenance Supervisor A confirmed this finding.

A
Based on observations, the facility failed to provide 1 emergency light unit in where required. This affects approximately 1 patient and 4 staff members. The facility had a license of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the Operating Room failed to be equipped with an emergency light unit.

Maintenance Supervisor A confirmed this finding.


B.
Based on observations, the facility failed to properly document the required testing of the buildings emergency light units. This affects all residents and staff at the facility. The facility had a license of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the facility failed to provide documentation of a 90 minute annual test of the buildings emergency light units.

Maintenance Supervisor A confirmed this finding.

Based on observations, the facility failed to assure exit signs were properly displayed and visible in the facility at 1 location. This affects approximately 2 patients and 3 staff members. The facility had a capacity of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the facility failed to provide a visible illuminated exit sign near Patient Room #125.

Maintenance Supervisor A confirmed this finding.

Based on observations, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by failing to meet the requirements of the remote dialer system. This affects all patients and staff members. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations on 2-14-11, revealed that when the remote dialer phone lines are disconnected, it failed to send an audible and visible trouble alarm to a location that is manned 24 hours a day. At the time of inspection, when the phone lines were disconnected, the audible alarm sounded at the main fire alarm panel which was located in the Fire Control Room.

Maintenance Supervisor A confirmed this finding.

A.
Based on observations and record review, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to provide the required documentation of quarterly inspections of the buildings automatic sprinkler system. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and record review on 2-14-11 revealed the facility failed to properly document and conduct quarterly inspections of the buildings automatic sprinkler system. The only documentation that the facility provided was a spreadsheet that showed the maintenance staff was checking the sprinkler heads.

Maintenance Supervisor A confirmed this finding.

B.
Based on observations and record review, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to document and conduct a 5 year internal obstruction test of the buildings automatic sprinkler system. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and record review on 2-14-11 revealed the facility failed to properly document and conduct a required 5 year internal obstruction test of the buildings sprinkler system.

Maintenance Supervisor A confirmed this finding.

C.
Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to provide the required number of spare sprinkler heads available for use. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations on 2-14-11 revealed the spare sprinkler box located near the sprinkler riser failed to be equipped with at least 6 Quick Response Heads. At the time of inspection, the box contained 5 Standard Response Heads and 2 Quick Response Heads.

Maintenance Supervisor A confirmed this finding.

D.
Based on observations and record review, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to meet the requirements of maintaining the facilities fire pump. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and record review on 2-14-11 revealed the facility failed to document the required 30 minute weekly test of the fire pump that supports the water pressure to the building automatic sprinkler system.

Maintenance Supervisor A confirmed this finding.

Based on observations, the facility failed to properly locate a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. This affects all occupants within the facility. The facility has a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations on 2-14-11, revealed the remote annunciator panel for the emergency generator was located in an area that was not manned by staff 24 hours a day (Chiller Room and Boiler Room, in the basement).

Maintenance Supervisor A confirmed this finding.

Based on observations, the facility failed to maintain the doors to 4 rooms in proper working order. This would affect approximately 6 patients and 4 staff members. The facility had a capacity of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the presence of "kick down" hold open devices on the bottom of the following doors.

1. The door to the 200 Wing Tub Room
2. The door to the C.T. Room
3. The door to the C.T. Control Room
4. The door to the O.R. Anit-Room

Maintenance Supervisor A confirmed these findings.

Based on observations, the facility failed to maintain 1 hazardous room properly separated by failing to properly maintain the doors to the room. This affects approximately 5 staff members only due to the fact that the deficiency occurred in a non-patient area (basement). The facility had a capacity of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11 revealed the 2 doors to the Laundry Room in the Basement failed to close and latch properly into the door frame when tested.

Maintenance Staff A confirmed this finding.

Based on observations, the facility failed to provide an approved exit discharge from 3 exits location in the facility. This affects all occupants within the facility. The facility had a license of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the facility failed to provide concrete or asphalt sidewalks that were at least 48 inches wide that provided exit discharge to a public sidewalk, public street or parking lot from the following exits.

1. The South Basement exit. This exit door was located below ground level. The exit discharge went up exterior of the building, ending abruptly in a grassy area.

2. The Elevator exit in the Basement. This exit door is located below ground level. The exit discharge went up exterior of the building, ending abruptly in a grassy area.

3. The exit from the O.B department.

Maintenance Supervisor A confirmed these findings.

Based on observations, the facility failed to provide proper illumination of the means of egress and exit discharge at 1 exit by not having at least 2 functioning exterior lights. This affects approximately 8 staff members only due to the fact that this deficiency occurred in a non-patient area. The facility had a capacity of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the exit discharge area from the South Basement Exit failed to be equipped with 2 light bulbs.

Maintenance Supervisor A confirmed this finding.

A
Based on observations, the facility failed to provide 1 emergency light unit in where required. This affects approximately 1 patient and 4 staff members. The facility had a license of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the Operating Room failed to be equipped with an emergency light unit.

Maintenance Supervisor A confirmed this finding.


B.
Based on observations, the facility failed to properly document the required testing of the buildings emergency light units. This affects all residents and staff at the facility. The facility had a license of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the facility failed to provide documentation of a 90 minute annual test of the buildings emergency light units.

Maintenance Supervisor A confirmed this finding.

Based on observations, the facility failed to assure exit signs were properly displayed and visible in the facility at 1 location. This affects approximately 2 patients and 3 staff members. The facility had a capacity of 25 patients and a census of 8 patients.

Findings include:

Observations on 2-14-11, revealed the facility failed to provide a visible illuminated exit sign near Patient Room #125.

Maintenance Supervisor A confirmed this finding.

Based on observations, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by failing to meet the requirements of the remote dialer system. This affects all patients and staff members. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations on 2-14-11, revealed that when the remote dialer phone lines are disconnected, it failed to send an audible and visible trouble alarm to a location that is manned 24 hours a day. At the time of inspection, when the phone lines were disconnected, the audible alarm sounded at the main fire alarm panel which was located in the Fire Control Room.

Maintenance Supervisor A confirmed this finding.

A.
Based on observations and record review, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to provide the required documentation of quarterly inspections of the buildings automatic sprinkler system. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and record review on 2-14-11 revealed the facility failed to properly document and conduct quarterly inspections of the buildings automatic sprinkler system. The only documentation that the facility provided was a spreadsheet that showed the maintenance staff was checking the sprinkler heads.

Maintenance Supervisor A confirmed this finding.

B.
Based on observations and record review, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to document and conduct a 5 year internal obstruction test of the buildings automatic sprinkler system. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and record review on 2-14-11 revealed the facility failed to properly document and conduct a required 5 year internal obstruction test of the buildings sprinkler system.

Maintenance Supervisor A confirmed this finding.

C.
Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to provide the required number of spare sprinkler heads available for use. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations on 2-14-11 revealed the spare sprinkler box located near the sprinkler riser failed to be equipped with at least 6 Quick Response Heads. At the time of inspection, the box contained 5 Standard Response Heads and 2 Quick Response Heads.

Maintenance Supervisor A confirmed this finding.

D.
Based on observations and record review, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to meet the requirements of maintaining the facilities fire pump. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations and record review on 2-14-11 revealed the facility failed to document the required 30 minute weekly test of the fire pump that supports the water pressure to the building automatic sprinkler system.

Maintenance Supervisor A confirmed this finding.

Based on observations, the facility failed to properly locate a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. This affects all occupants within the facility. The facility has a capacity of 25 residents and a census of 8 residents.

Findings include:

Observations on 2-14-11, revealed the remote annunciator panel for the emergency generator was located in an area that was not manned by staff 24 hours a day (Chiller Room and Boiler Room, in the basement).

Maintenance Supervisor A confirmed this finding.