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Based on observation and interview, the facility failed to maintain a smoke tight ceiling. The building is composed of Type II protected construction and is required by the Life Safety Code 19.1.6.2, to maintain smoke tight ceilings if used for healthcare occupancy. This deficient practice affects all 2-3 staff and two (2) of six (6) smoke zones. This facility has a capacity of 25 and a census of 8 residents.
Findings include:
1.) Observations and interview on 01/18/13 at 11:58 a.m., revealed one (1) of four (4) sprinkler heads in the Pharmacy at the Hancock County Hospital was missing an escution ring leaving a gap in the ceiling.
2.) Observations and interview on 01/18/13 at 12:09 p.m., revealed one (1) of three (3) sprinkler heads in the Medical records Office at the Hancock County Hospital was missing an escution ring leaving a gap in the ceiling.
3.) Observations and interview on 01/17/13 at 12:01 p.m., revealed the Utility Room Attic Access was a section of OSB board instead of drywall.
4.) Observations and interview on 01/17/13 at the Garner Clinic, revealed the Main Mechanical Room had numerous penetrations in the walls and ceiling from a 1/4 inch to 1/2 inch in size in the gypsum wall and ceiling.
5.) Observations and interview on 01/17/13 at the garner Clinic, revealed the West Mechanical room had numerous penetrations in the wall s and ceiling from 1/4 inch to 1/2 inch in size in the gypsum wall and ceiling.
Maintenance Staff A verified these findings.

Based on observation and interview, the facility failed to maintain fire resistive rated corridor walls the associated clinics. Two (2) of the four (4) off-site clinics were affected by this deficient practice could affect 2-3 staff members. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

1.) Observations and interview on 01/17/13 at 11:21 a.m., revealed that the Patient Care Rooms at the Kanawha Clinic had a 1/4 inch to 1/2 inch gap around the sink drain lines and water lines. The walls were a gypsum wall and this was open to the wall cavity.
2.) Observations and interview on 01/17/13 at 1:23 p.m., revealed that the Northeast Restroom at the Garner Clinic had a 1/4 inch to 1/2 inch gap around the sink drain lines and water lines. The walls were a gypsum wall and this was open to the wall cavity.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain unobstructed corridors that provides a clear path of egress. This issue affect two (2) of the four (4) off-site clinics. This facility has a capacity of 25 with a census of 8.

Findings Include:

1.) Observations and interview on 01/17/13 at 11:15 a.m., revealed the charting station outside the Patient Rooms at the Kanawha Clinic did not retract when tested.

2.) Observations and interview on 01/18/13 at 10:05 a.m., revealed the charting stations (3) outside the Patient Rooms at the Britt Clinic did not retract when tested.

Maintenance Staff A verified these findings.

Based on observations and interview, the facility failed to maintain the emergency lights in the Garner Clinic. This deficient practice could affect 5-10 residents, staff and visitors tot he facility. This facility is licensed for 25 and had a census of 8.

Findings Include:

Observations and interview on 01/17/13 at 11:19 a.m., revealed the facility was not properly maintaining the Emergency lights in the Garner Clinic. The emergency lights Northwest Exit Door did not illuminate when tested.

Maintenance Staff A verified this finding.

Based on observations and interview, the facility failed to maintain the exit signs in the Garner Clinic. This deficient practice could affect 5-10 residents, staff and visitors tot he facility. This facility is licensed for 25 and had a census of 8.

Findings Include:

Observations and interview on 01/17/13 at 11:19 a.m., revealed the facility was not properly maintaining the Exit lights in the Garner Clinic. The exit sign Southwest Exit Door did not illuminate when tested.

Maintenance Staff A verified this finding.

Based on observation, record review and interview, the facility failed to conduct fire drills at varied times during the year on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

Review of the facility's fire drill records on 01/18/13, revealed that fire drills were conducted with in an hour of each other during to success quarters on the Day shift. The Evening shift had 3 of the 4 drills conducted within an hour of each other. The night shift had 2 of the 4 drills completed within an hour of each other. Also all 4th Quarter Drills were conducted in the month of December

Administrative Staff A & Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6 of NFPA 101 by ensuring that an approved Fire Alarm System was installed and maintained. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 8.

Findings include:

Observations and interview of the Hancock County Hospital on 01/18/13 at 12:22 p.m., reveled the facility failed to provide a smoke detector within 5 feet of the elevator door at the 2nd floor atrium.

Maintenance Staff A verified this observation.

A.) Based on observation and interview, the facility failed to properly use power strips in the Hancock County Hospital. The location of deficient practice was located in one (1) of six (6) smoke compartments affecting approximately 5 staff members and up to 25 residents in that compartment. The facility has a capacity of 25 and a census of 8 at the time of the survey.

Findings include:

Observations and interview in the Hancock County Hospital on 01/18/13 at 11:52 a.m., reveled a Scentsy Pot plugged in to a power strip in the 2nd Floor Nurses Office.


B.) Based on observation and interview in the Hancock County hospital, 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 the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 8 at the time of the survey.

Findings Include:

Observations and interview on 01/18/13 at 10:51 a.m., revealed the facility failed to maintain the electrical system in the Laundry Area. The 220v outlet for the dryer was missing a cover plate exposing the wires to the outlet.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain a smoke tight ceiling. The building is composed of Type II protected construction and is required by the Life Safety Code 19.1.6.2, to maintain smoke tight ceilings if used for healthcare occupancy. This deficient practice affects all 2-3 staff and two (2) of six (6) smoke zones. This facility has a capacity of 25 and a census of 8 residents.
Findings include:
1.) Observations and interview on 01/18/13 at 11:58 a.m., revealed one (1) of four (4) sprinkler heads in the Pharmacy at the Hancock County Hospital was missing an escution ring leaving a gap in the ceiling.
2.) Observations and interview on 01/18/13 at 12:09 p.m., revealed one (1) of three (3) sprinkler heads in the Medical records Office at the Hancock County Hospital was missing an escution ring leaving a gap in the ceiling.
3.) Observations and interview on 01/17/13 at 12:01 p.m., revealed the Utility Room Attic Access was a section of OSB board instead of drywall.
4.) Observations and interview on 01/17/13 at the Garner Clinic, revealed the Main Mechanical Room had numerous penetrations in the walls and ceiling from a 1/4 inch to 1/2 inch in size in the gypsum wall and ceiling.
5.) Observations and interview on 01/17/13 at the garner Clinic, revealed the West Mechanical room had numerous penetrations in the wall s and ceiling from 1/4 inch to 1/2 inch in size in the gypsum wall and ceiling.
Maintenance Staff A verified these findings.

Based on observation and interview, the facility failed to maintain fire resistive rated corridor walls the associated clinics. Two (2) of the four (4) off-site clinics were affected by this deficient practice could affect 2-3 staff members. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

1.) Observations and interview on 01/17/13 at 11:21 a.m., revealed that the Patient Care Rooms at the Kanawha Clinic had a 1/4 inch to 1/2 inch gap around the sink drain lines and water lines. The walls were a gypsum wall and this was open to the wall cavity.
2.) Observations and interview on 01/17/13 at 1:23 p.m., revealed that the Northeast Restroom at the Garner Clinic had a 1/4 inch to 1/2 inch gap around the sink drain lines and water lines. The walls were a gypsum wall and this was open to the wall cavity.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain unobstructed corridors that provides a clear path of egress. This issue affect two (2) of the four (4) off-site clinics. This facility has a capacity of 25 with a census of 8.

Findings Include:

1.) Observations and interview on 01/17/13 at 11:15 a.m., revealed the charting station outside the Patient Rooms at the Kanawha Clinic did not retract when tested.

2.) Observations and interview on 01/18/13 at 10:05 a.m., revealed the charting stations (3) outside the Patient Rooms at the Britt Clinic did not retract when tested.

Maintenance Staff A verified these findings.

Based on observations and interview, the facility failed to maintain the emergency lights in the Garner Clinic. This deficient practice could affect 5-10 residents, staff and visitors tot he facility. This facility is licensed for 25 and had a census of 8.

Findings Include:

Observations and interview on 01/17/13 at 11:19 a.m., revealed the facility was not properly maintaining the Emergency lights in the Garner Clinic. The emergency lights Northwest Exit Door did not illuminate when tested.

Maintenance Staff A verified this finding.

Based on observations and interview, the facility failed to maintain the exit signs in the Garner Clinic. This deficient practice could affect 5-10 residents, staff and visitors tot he facility. This facility is licensed for 25 and had a census of 8.

Findings Include:

Observations and interview on 01/17/13 at 11:19 a.m., revealed the facility was not properly maintaining the Exit lights in the Garner Clinic. The exit sign Southwest Exit Door did not illuminate when tested.

Maintenance Staff A verified this finding.

Based on observation, record review and interview, the facility failed to conduct fire drills at varied times during the year on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 8 residents.

Findings include:

Review of the facility's fire drill records on 01/18/13, revealed that fire drills were conducted with in an hour of each other during to success quarters on the Day shift. The Evening shift had 3 of the 4 drills conducted within an hour of each other. The night shift had 2 of the 4 drills completed within an hour of each other. Also all 4th Quarter Drills were conducted in the month of December

Administrative Staff A & Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6 of NFPA 101 by ensuring that an approved Fire Alarm System was installed and maintained. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 8.

Findings include:

Observations and interview of the Hancock County Hospital on 01/18/13 at 12:22 p.m., reveled the facility failed to provide a smoke detector within 5 feet of the elevator door at the 2nd floor atrium.

Maintenance Staff A verified this observation.

A.) Based on observation and interview, the facility failed to properly use power strips in the Hancock County Hospital. The location of deficient practice was located in one (1) of six (6) smoke compartments affecting approximately 5 staff members and up to 25 residents in that compartment. The facility has a capacity of 25 and a census of 8 at the time of the survey.

Findings include:

Observations and interview in the Hancock County Hospital on 01/18/13 at 11:52 a.m., reveled a Scentsy Pot plugged in to a power strip in the 2nd Floor Nurses Office.


B.) Based on observation and interview in the Hancock County hospital, 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 the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 8 at the time of the survey.

Findings Include:

Observations and interview on 01/18/13 at 10:51 a.m., revealed the facility failed to maintain the electrical system in the Laundry Area. The 220v outlet for the dryer was missing a cover plate exposing the wires to the outlet.

Maintenance Staff A verified this observation.