HospitalInspections.org

(A)
Based on observation, this facility is not providing the appropriate construction standards as required by the Life Safety Code. This facility contains a tunnel that connects to the building and parking lot, which composed of combustible construction and is required to be completely sprinklered. This deficient practice affects all occupants of the building. This facility has 25 certified beds.

Findings include:

Observation on 8/11/10 revealed the facility is composed of non-combustible construction and is fully sprinklered. The back tunnel to parking lot is composed of combustible construction and in excess of four feet wide was not sprinklered.

(B)
Based on observation, the facility is not providing a smoke tight ceiling in the two of eleven smoke zones. This deficient practice affects all occupants of the cafeteria area and 1st floor Maintenance. This facility has 25 certified beds.

Findings include:

Observation on 8/11/10, revealed two smoke zones contained sprinkler penetrations located in the ceiling:

1. The Washing area of the Kitchen contained two penetrations surrounding the two sprinkler heads located in the ceiling, these penetrations were 1/2 inch in size.

2. The 1st floor corridor(back hall) contained two penetrations surrounding the two sprinkler heads located in the ceiling, these penetrations were 1/2 to 1 inch in size.

(A)
Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of eleven smoke compartments and could affect approximately all residents and staff members. This facility has a 25 certified beds.

Findings include:

Observation of the Electrical room (Fire alarm panel room) on 8/11/19, revealed that the room contained several holes and pipe penetrations throughout.


Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of eleven smoke compartments and could affect approximately 25 residents and staff members. This facility has a 25 certified beds.

Findings include:

During observation of the Electrical room (Fire alarm panel room) on 8/11/10, revealed that the corridor door to the room was not equipped with the self closing mechanism.

Based on record review and interview the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects eleven of eleven smoke compartments and all occupants of the facility. This facility has a 25 certifed beds.

Findings include:

Record review and staff interview on 8/11/10, revealed that there was no documentation showing the testing of the emergency battery lighting system was conducted for 30 seconds monthly and 90 minutes annually. According to Maintenance Staff A, the lights were tested monthly.

Based upon 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 25 certified beds.

Findings include:

Record review on 8/11/10, revealed all of the second shift drills were conducted within the same hour during all four quarters.

(A)
Based on record review, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility has 25 certified beds.

Findings include:

Record review on 8/11/10, revealed the facility was unable to produce documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacturer.

(B)
Based on observation, this 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 that three feet to air supply or air return. This can affect all occupants of the building. This facility has a 25 certified beds.

Findings include:

Observation on 8/11/10, the smoke detector located between Pods A and C of the Speciality area was located less than three feet from an air supply.

Based on observation, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The facility has 25 certified beds.

Findings include:

Observation on 8/11/10, the sprinkler head located in the washing area of the Kitchen contained drywall mud, which was covering the arms and deflector.

Based on record review, the facility did not assure that all the smoke dampers located in building were inspected by an outside company. This deficient practice effects all the occupants of nine smoke zones, including staff, visitors and residents, who may need to use these areas as a safe zone in the event of an emergency. This facility has 25 certified beds.

Finding include:

Record review on 8/11/10 of the documentation shows no testing of the smoke dampers located in the building by an outside company.

Based on observation and staff interview, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. The absence of a remote annunciator for the emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 25 certified beds.

Findings include:

Observation on 8/11/10, revealed the absence of a remote annunciator panel (storage battery powered) for the emergency generator.

(A)
Based on observation, this facility is not providing the appropriate construction standards as required by the Life Safety Code. This facility contains a tunnel that connects to the building and parking lot, which composed of combustible construction and is required to be completely sprinklered. This deficient practice affects all occupants of the building. This facility has 25 certified beds.

Findings include:

Observation on 8/11/10 revealed the facility is composed of non-combustible construction and is fully sprinklered. The back tunnel to parking lot is composed of combustible construction and in excess of four feet wide was not sprinklered.

(B)
Based on observation, the facility is not providing a smoke tight ceiling in the two of eleven smoke zones. This deficient practice affects all occupants of the cafeteria area and 1st floor Maintenance. This facility has 25 certified beds.

Findings include:

Observation on 8/11/10, revealed two smoke zones contained sprinkler penetrations located in the ceiling:

1. The Washing area of the Kitchen contained two penetrations surrounding the two sprinkler heads located in the ceiling, these penetrations were 1/2 inch in size.

2. The 1st floor corridor(back hall) contained two penetrations surrounding the two sprinkler heads located in the ceiling, these penetrations were 1/2 to 1 inch in size.

(A)
Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of eleven smoke compartments and could affect approximately all residents and staff members. This facility has a 25 certified beds.

Findings include:

Observation of the Electrical room (Fire alarm panel room) on 8/11/19, revealed that the room contained several holes and pipe penetrations throughout.


Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of eleven smoke compartments and could affect approximately 25 residents and staff members. This facility has a 25 certified beds.

Findings include:

During observation of the Electrical room (Fire alarm panel room) on 8/11/10, revealed that the corridor door to the room was not equipped with the self closing mechanism.

Based on record review and interview the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects eleven of eleven smoke compartments and all occupants of the facility. This facility has a 25 certifed beds.

Findings include:

Record review and staff interview on 8/11/10, revealed that there was no documentation showing the testing of the emergency battery lighting system was conducted for 30 seconds monthly and 90 minutes annually. According to Maintenance Staff A, the lights were tested monthly.

Based upon 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 25 certified beds.

Findings include:

Record review on 8/11/10, revealed all of the second shift drills were conducted within the same hour during all four quarters.

(A)
Based on record review, the facility failed to maintain and test smoke detectors for sensitivity in accordance with NFPA 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. The facility has 25 certified beds.

Findings include:

Record review on 8/11/10, revealed the facility was unable to produce documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacturer.

(B)
Based on observation, this 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 that three feet to air supply or air return. This can affect all occupants of the building. This facility has a 25 certified beds.

Findings include:

Observation on 8/11/10, the smoke detector located between Pods A and C of the Speciality area was located less than three feet from an air supply.

Based on observation, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The facility has 25 certified beds.

Findings include:

Observation on 8/11/10, the sprinkler head located in the washing area of the Kitchen contained drywall mud, which was covering the arms and deflector.

Based on record review, the facility did not assure that all the smoke dampers located in building were inspected by an outside company. This deficient practice effects all the occupants of nine smoke zones, including staff, visitors and residents, who may need to use these areas as a safe zone in the event of an emergency. This facility has 25 certified beds.

Finding include:

Record review on 8/11/10 of the documentation shows no testing of the smoke dampers located in the building by an outside company.

Based on observation and staff interview, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. The absence of a remote annunciator for the emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 25 certified beds.

Findings include:

Observation on 8/11/10, revealed the absence of a remote annunciator panel (storage battery powered) for the emergency generator.