HospitalInspections.org

Based on observations and interview, the facility failed to maintain 2 smoke barriers free of penetrations. This affects 4 smoke zones within the facility. The facility had a license of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 11:01 am and 11:18 am revealed the following:

1. A pipe penetration (approximately 1 inch each in size) located above the suspended ceiling in the smoke barrier near the Lab.

2. 2 pipe penetrations (approximately 1/2 inch in size each) and a wire penetration (approximately 1/4 inch in size) located above the suspended ceiling in the South Smoke Barrier near the Main Lobby/Registration doors.

Staff Member A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to properly maintain 1 special locking arrangement door (15 second delay) by failing to have the proper signage located on the door. This affects 1 smoke zone in the facility. The facility had a license of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 11:52 am revealed the 15 second delay egress door located at the north exit from the O.B. Department failed to have the proper signage installed on the door. The facility shall install a sign on the door that reads: "PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS".

Maintenance Staff A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to alter the times of the fire drills. This would affect all the smoke zones in the facility. The facility had a capacity of 25 patients and a census of 12 patients.

Findings include:

Record review and interview on 2-3-16 at approximately 9:02 am revealed the facility failed to alter the times of the fire drills conducted on the 1st nursing shift during the previous 12 months. The times of 3 out of 4 fire drills conducted on the 1st nursing shift only varied 21 minutes.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by improperly locating 2 smoke detectors. This affects 2 smoke zones in the facility. The facility had a license of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 11:45 am and 11:46 am revealed the following:

1. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Nurses Substation/OMNI Room.

2. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Staff Only Room near the Nurses Substation/OMNI Room.

Maintenance Staff A verified these observations during the survey process.

Based on observations and interview, 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 obstructing sprinkler heads with storage. This affects 1 smoke zone in the facility. The facility had a capacity of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 10:54 am revealed combustible storage that was located closer than 18 inches from the bottom of the sprinkler deflector located in the small Linen Closet in the Laundry Room.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, 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 by allowing unapproved electrical adapters to be in use. This affects 2 smoke zones in the facility. The facility had a licence of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 11:29 am and 11:31 am revealed the following:

1. A 3 way electrical adapter located in the Respiratory Therapy Office.

2. A 6-way electrical adapter located in the corridor near the Gift Shop.

Maintenance Staff A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to have an Alcohol Based Hand Rub dispensers properly located in the facility. This affects 1 smoke zone in the facility. The facility has a capacity of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 11:27 am revealed an Alcohol Based Hand Rub dispenser that was located above an electrical source (electrical outlet) in the Gift Shop Storage Room.

Staff Member A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain 2 smoke barriers free of penetrations. This affects 4 smoke zones within the facility. The facility had a license of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 11:01 am and 11:18 am revealed the following:

1. A pipe penetration (approximately 1 inch each in size) located above the suspended ceiling in the smoke barrier near the Lab.

2. 2 pipe penetrations (approximately 1/2 inch in size each) and a wire penetration (approximately 1/4 inch in size) located above the suspended ceiling in the South Smoke Barrier near the Main Lobby/Registration doors.

Staff Member A verified these observations at the time of the survey process.

Based on observations and interview, the facility failed to properly maintain 1 special locking arrangement door (15 second delay) by failing to have the proper signage located on the door. This affects 1 smoke zone in the facility. The facility had a license of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 11:52 am revealed the 15 second delay egress door located at the north exit from the O.B. Department failed to have the proper signage installed on the door. The facility shall install a sign on the door that reads: "PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS".

Maintenance Staff A verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to alter the times of the fire drills. This would affect all the smoke zones in the facility. The facility had a capacity of 25 patients and a census of 12 patients.

Findings include:

Record review and interview on 2-3-16 at approximately 9:02 am revealed the facility failed to alter the times of the fire drills conducted on the 1st nursing shift during the previous 12 months. The times of 3 out of 4 fire drills conducted on the 1st nursing shift only varied 21 minutes.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by improperly locating 2 smoke detectors. This affects 2 smoke zones in the facility. The facility had a license of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 11:45 am and 11:46 am revealed the following:

1. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Nurses Substation/OMNI Room.

2. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Staff Only Room near the Nurses Substation/OMNI Room.

Maintenance Staff A verified these observations during the survey process.

Based on observations and interview, 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 obstructing sprinkler heads with storage. This affects 1 smoke zone in the facility. The facility had a capacity of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 10:54 am revealed combustible storage that was located closer than 18 inches from the bottom of the sprinkler deflector located in the small Linen Closet in the Laundry Room.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, 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 by allowing unapproved electrical adapters to be in use. This affects 2 smoke zones in the facility. The facility had a licence of 25 patients and a census of 12 patients.

Findings include:

Observations and interview on 2-3-16 at approximately 11:29 am and 11:31 am revealed the following:

1. A 3 way electrical adapter located in the Respiratory Therapy Office.

2. A 6-way electrical adapter located in the corridor near the Gift Shop.

Maintenance Staff A verified these observations at the time of the survey process.