HospitalInspections.org

Based on observation and interview,the facility failed to provide a directional exit sign at the end of the corridor for one exit. This deficient practice affects approximately 28 residents, staff and visitors in the facility. The facility has a capacity of 49 and a census of 28.

Findings include:

Observation and interview on 04/17/2018 at 9:39 a.m., revealed the facility failed to maintain a directional exit sign in the corridor near the B to C Building Smoke Barrier. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, 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 28 residents, staff and visitors in this smoke compartment. The facility has a capacity of 49 and a census of 28.

Findings include:

1. Observation and interview on 04/17/2018 at 9:27 a.m., revealed the facility failed to maintain the Fire Alarm System in the Fourth Floor Marketing Graphic Office. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 04/17/2018 at 9:28 a.m., revealed the facility failed to maintain the Fire Alarm System in the Fourth Floor corridor across from Human Resources Generalists Office. This corridor contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

3. Observation and interview on 04/17/2018 at 9:30 a.m., revealed the facility failed to maintain the Fire Alarm System in the Fourth Floor Recruitment Specialists Office. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

4. Observation and interview on 04/17/2018 at 9:31 a.m., revealed the facility failed to maintain the Fire Alarm System in the Fourth Floor Human Resources Generalists Office. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

5. Observation and interview on 04/17/2018 at 9:32 a.m., revealed the facility failed to maintain the Fire Alarm System in the Fourth Floor Recruiter Office. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

6. Observation and interview on 04/17/2018 at 9:34 a.m., revealed the facility failed to maintain the Fire Alarm System in the Fourth Floor Human Resources Lobby. This lobby contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

7. Observation and interview on 04/17/2018 at 9:35 a.m., revealed the facility failed to maintain the Fire Alarm System in the Fourth Floor North Administrative offices. These rooms contained six smoke detectors with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

8. Observation and interview on 04/17/2018 at 9:35 a.m., revealed the facility failed to maintain the Fire Alarm System in the Third Floor Environmental Services Directors Office. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

9. Observation and interview on 04/17/2018 at 9:37 a.m., revealed the facility failed to maintain the Fire Alarm System in the Third Floor Public Health Nurses Office. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

10. Observation and interview on 04/17/2018 at 10:40 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near resident room #220. This corridor contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

11. Observation and interview on 04/17/2018 at 10:42 a.m., revealed the facility failed to maintain the Fire Alarm System in the lobby near the second floor elevator doors. This lobby contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

12. Observation and interview on 04/17/2018 at 10:44 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near resident room #247. This corridor contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

13. Observation and interview on 04/17/2018 at 11;18 a.m., revealed the facility failed to maintain the Fire Alarm System in the Business Office corridor near the west exit door. This corridor contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

14. Observation and interview on 04/17/2018 at 11:20 a.m., revealed the facility failed to maintain the Fire Alarm System in the second floor south Business Office corridor. This corridor contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

15. Observation and interview on 04/17/2018 at 11:25 a.m., revealed the facility failed to maintain the Fire Alarm System in the Business office Department Directors office. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

16. Observation and interview on 04/17/2018 at 11:30 a.m., revealed the facility failed to maintain the Fire Alarm System in the second floor Business Office Financial Services Departments Office. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

17. Observation and interview on 04/17/2018 at 2:12 p.m., revealed the facility failed to maintain the Fire Alarm System in the Emergency Room corridor near exam room #12.. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

18. Observation and interview on 04/17/2018 at 2:14 p.m., revealed the facility failed to maintain the Fire Alarm System in Intensive Care Unit room #6. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

19. Observation and interview on 04/17/2018 at 2:15 p.m., revealed the facility failed to maintain the Fire Alarm System in the O.B. Kitchen. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

20. Observation and interview on 04/17/2018 at 2:16 p.m., revealed the facility failed to maintain the Fire Alarm System in O.B. resident rooms #101, #104, #106, #107 and #108. These rooms contained smoke detectors with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

21. Observation and interview on 04/17/2018 at 2:20 p.m., revealed the facility failed to maintain the Fire Alarm System in Conference Room D. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

22. Observation and interview on 04/17/2018 at 2:40 p.m., revealed the facility failed to maintain the Fire Alarm System in the S.H.I.I.P. Room.. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

23. Observation and interview on 04/17/2018 at 2:40 p.m., revealed the facility failed to maintain the Fire Alarm System in the S.H.I.I.P. Counseling Room. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

24. Observation and interview on 04/17/2018 at 2:40 p.m., revealed the facility failed to maintain the Fire Alarm System in the room next to the Lab in the Pathology Services Area. This room contained a smoke detector with in three feet of an air diffuser. The Maintenance Director verified this observation at the time of the survey process.

Based on interview and record review, the facility did not maintain complete documentation of the testing of the fire alarm system as required by NFPA 72. This deficient practice of not providing complete and verifiable documentation of the inspection, testing, and maintenance of the fire alarm system does not ensure proper operation and prompt repair affecting all occupants in the facility. The facility has a capacity of 49 with a census of 28.

Findings include:

Based on observation and record review on 4/19/2018 at 1:27 p.m., revealed the facility was unable to produce documentation that the smoke detector sensitivity testing had been completed in the last twenty four months. The last documented test was completed on 4/23/2014 and verified by the Maintenance Director through record review at the time of the survey process.

Based on observation and interview, the facility failed to ensure the sprinkler system is installed properly. The deficient practice of failing to maintain at least a four inch distance from the wall will increase the sprinkler's operation time due to dead air space. This affected approximately 28 residents in the facility with a capacity of 49 with a census of 28.

Findings include:

1. Observation and interview on 04/17/2018 at 12:50 p.m., revealed the facility failed to have the sprinkler system properly installed. The OBGYN Sprinkler Riser Room had a pendant sprinkler installed within 1/2 inch of the wall. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 04/19/2018 at 9:00 a.m., revealed the facility failed to have the sprinkler system properly installed. The Ambulatory Surgical Center Mechanical Room contained two pendant heads that were not properly secured and contained protective plastic covers over the fusible links. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 2011 edition of NFPA 25, by ensuring quarterly testing and that sprinkler heads have an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This 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 49 and a census of 28.

Findings include:


1. Observation and interview on 4/17/2018 at 11:40 a.m., revealed the facility failed to maintain the sprinkler system in the Clinical Engineering corridor. This corridor contained gray wire zip tied to the sprinkler pipe. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 4/17/2018 at 11:52 a.m., revealed the facility failed to maintain the sprinkler system in the Boiler Room. This room contained white wire zip tied to the sprinkler pipe above the water heater. The Maintenance Director verified this observation at the time of the survey process.

3. Observation and interview on 4/17/2018 at 11:56 a.m., revealed the facility failed to maintain the sprinkler system in the Kitchen near the Loading Dock. This room contained white wire zip tied to the sprinkler pipe. The Maintenance Director verified this observation at the time of the survey process.

4. Observation and interview on 4/17/2018 at 2:06 p.m., revealed the facility failed to maintain the sprinkler system in the Morgue corridor. This corridor contained red wires zip tied to the sprinkler pipe. The Maintenance Director verified this observation at the time of the survey process.

5. Observation and interview on 4/17/2018 at 2:28 p.m., revealed the facility failed to maintain the sprinkler system in the Building D Electrical Room. This room contained red wires zip tied to the sprinkler pipe. The Maintenance Director verified this observation at the time of the survey process.

6. Observation and record review on 4/19/2018 at 1:26 p.m., revealed the facility failed to maintain the sprinkler system. The facility failed to conduct quarterly in the first, second and fourth quarter of 2017. The Maintenance Director verified this through record review at the time of the survey process.

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. This deficient practice could affect 28 residents, staff and visitors in the facility. The facility has a capacity of 49 and a census of 28.

Findings include:

Observation and interview of the fire extinguishers on 04/17/2018 at 2:10 p.m., revealed the facility failed to maintain one fire extinguisher in the Laundry Room. This extinguisher was not secured to the wall. The Maintenance Director verified this observation at the time of the survey process.

Based on observation this facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls 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 28 residents, staff, and visitors in the facility. The facility has a capacity of 49 with a census of 28.

Findings include:

1. Observation and interview on 04/17/2018 at 10:02 a.m., revealed the A to B Building Smoke Barrier contained a conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 04/17/2018 at 10:50 a.m., revealed the second floor B to C Building Smoke Barrier contained a bundle of blue and white wires with a 1/2 inch gap above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified this observation at the time of the survey process.

3. Observation and interview on 04/19/2018 at 9:10 a.m., revealed the Ambulatory Surgical Center Smoke Barrier near Electrical Room #2108 contained two 1/2 inch conduits with open centers above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified this observation at the time of the survey process.

4. Observation and interview on 04/19/2018 at 9:12 a.m., revealed the Ambulatory Surgical Center Smoke Barrier near Electrical Room #2108 contained a 3/4 inch conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified this observation at the time of the survey process.

5. Observation and interview on 04/19/2018 at 9:15 a.m., revealed the Ambulatory Surgical Center Smoke Barrier near Room #2202 contained a 1/2 inch conduit with an open center above the lay in tile. According to the facility layout, this was a required barrier. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. This deficient practice could affect 28 residents, staff and visitors in the facility. The facility has a capacity of 49 and a census of 28.

Findings include:

Observation and interview on 04/17/2018 at 10:00 a.m., revealed the facility failed to maintain the B to C Smoke Barrier doors in proper working condition. These double doors failed to close and positively latch while being tested. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, affecting one staff in this room. The facility had a capacity of 49 and a census of 28.

Findings Include:

1. Observation and interview on 04/17/2018 at 10:38 a.m., revealed the facility failed to maintain the electrical system in the Clean Linen Room near Resident Room #312. This room contained a standard outlet near the sink. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and interview on 04/17/2018 at 11:35 a.m., revealed the facility failed to maintain the electrical system in the I.T. Storage Room. This room contained a three way adapter supplying power to a projector along the ceiling. The Maintenance Director verified this observation at the time of the survey process.

3. Observation and interview on 04/17/2018 at 11:38 a.m., revealed the facility failed to maintain the electrical system in the Building C second floor south Mechanical Room . This room contained a open junction box along the wall. The Maintenance Director verified this observation at the time of the survey process.

4. Observation and interview on 04/17/2018 at 11:50 a.m., revealed the facility failed to maintain the electrical system in the Boiler Room near the Loading Dock . This room contained a open junction box along the north wall. The Maintenance Director verified this observation at the time of the survey process.

5. Observation and interview on 04/17/2018 at 2:04 p.m., revealed the facility failed to maintain the electrical system in the Light Bulb Room . This room contained a open ended conduit with exposed wires along the ceiling. The Maintenance Director verified this observation at the time of the survey process.

6. Observation and interview on 04/17/2018 at 2:08 p.m., revealed the facility failed to maintain the electrical system in the Main Boiler Room . This room contained two open junction boxes with exposed wires along the ceiling. The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 49 and a census of 28.

Findings include:

1. Observation and interview on 04/17/2018 at 2:50 p.m., revealed that the facility's generator was located indoors and there was not an emergency stop mechanism located outside the generator room in accordance with NFPA 110. The Maintenance Director verified this observation at the time of the survey process.

2. Observation and staff interview on 04/19/2018 at 10:20 a.m., revealed the absence of a remote annunciator panel (storage battery powered) for the emergency generator in a staffed or monitored location. The Maintenance Director verified this observation at the time of the survey process.