HospitalInspections.org

Based on observation and interview, the facility was a Type I/Type II building construction and the facility failed to provide/maintain interior walls/partitions that were built with noncombustible or limited combustible materials in accordance with Section 19.1.6.3 of the 2000 Life Safety Code. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 09/23/15 at 11:50 AM, revealed a hole (approximately 3 inches) located in the Filter Room.
2. Observations and staff interviews on 09/23/15 at 11:51 AM, revealed holes(approximately 1/2 inch) located in the North Stairway.
3. Observations and staff interviews on 09/23/15 at 1:32 PM, revealed a hole (approximately 2x2 inches) located in the Basement Locker Room.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain resident room doors in proper working condition to close and latch properly into the door frame with the swing of the door closer in accordance with Section 19.3.6.3.1 of the 2000 Life Safety Code. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 09/23/15 at 11:50 AM, revealed a trash can that was being used to hold the door to Room 111 open.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 09/23/15 at 1:17 pm, revealed the door closer located on the Boiler Room Door did not operate properly when tested during this survey.
2. Observations and staff interviews on 09/23/15 at 1:30 pm, revealed the door to the Storage room located in the Basement by the stairway was not equipped with door closing hardware.
3. Observations and staff interviews on 09/23/15 at 1:35 pm, revealed the door to the storage room located by the Business Office was not equipped with self closing hardware.
4. Observations and staff interviews on 09/23/15 at 2:10 pm, revealed the self closing hardware was not functioning on the door to the Mail Room.
5. Observations and staff interviews on 09/23/15 at 2:35 pm, revealed the door closing hardware located on the door to Room 411 Film Storage Room did not operate properly when tested during this survey.
6. Observations and staff interviews on 09/23/15, revealed the door closing hardware on the doors to Rooms 405, 409 were present but were disabled and did not function properly.
7. Observations and staff interviews on 09/23/15 at 2:40 pm, revealed the door to Room CT Scan Room was not equipped with self closing hardware.
8. Observations and staff interviews on 09/23/15 at 2:44 pm, revealed the door to Room 800 HR Accounting Room was not equipped with self closing hardware.

Maintenance Staff verified these observations.

Based on observation and interview, the facility failed to maintain Stairways/Smokeproof towers in accordance with Sections 19.2.2.3, 19.2.2.4, and 7.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 09/23/15 at 11:51 AM, revealed items were being stored in the North Stairway.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain exits in smoke zones easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 09/23/15 at 1:00 pm, revealed the North Exit door in the Basement was locked using a hasp bolt locks and proper exit signs were not installed.
2. Observations and staff interviews on 09/23/15 at 2:35 pm, revealed items being stored in the corridors by the exit doors by Exam Room 2.
3. Observations and staff interviews on 09/23/15 at 3:20 pm, revealed dirty laundry containers being stored in the corridors in the North Hall. These containers were not in use.

Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide the required 90 minute annual and 30 second/30 day testing of the emergency lighting units throughout the facility as required by Sections 19.2.9.1 and 7.9 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include.
1. Observations, record review and staff interviews on 09/23/15 at 10:17 am, revealed the facility did not provide documentation of the 30 day 30 second tests and the annual 90 minute test.
2. Observations and staff interviews on 09/23/15 at 3:03 pm, revealed the emergency lights located in Room 409 did not function properly when tested during this survey.
Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide fire drills for the staff as required by Section 19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.

Findings Include:

Observations, record review and staff interviews on 09/23/15 at 11:15, revealed the facility conducted three of four day shift fire drills between 1:10 pm and 2:00 pm. It also conducted three of four evening shiff between 5:10 pm and 6:30 pm.

Maintenance Staff A verified these observations.

Based on record review/observation and interview, the facility failed to provide/maintain a sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition within the facility that was in accordance with that National Fire Protection Association (NFPA) Standard 13, Installation of Sprinkler Systems, 1999 edition and was properly interconnected with the facility ' s fire alarm system in accordance with the NFPA Standard 72, National Fire Alarm Code, 1999 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include.
Observations, record review and staff interviews on 09/23/15 at 11:10, revealed the facility failed to provide documentation of the required quarterly inspections of the facilities sprinkler system. The only documentation provided was an annual inspection which occurred on 10/22/14. No documentation was provide for the required 5 year internal inspection.
Maintenance Staff A verified these observations.

Based on observation, and interview, the facility failed to provide/maintain the building ' s sprinkler system in reliable operating condition and/or maintain proper testing and maintenance in accordance with the National Fire Protection Association (NFPA) Standard 25, Inspections, Testing, and Maintenance of Sprinkler Systems, 1998 edition, the NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1998 edition, and Sections 19.7.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 09/23/15 at 1:10 pm, revealed a dirty sprinkler head located in Room 134.
2. Observations and staff interviews on 09/23/15 at 1:40 pm, revealed the Elevator Maintenance Room did not have sprinkler coverage.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility was a Type I/Type II building construction and the facility failed to provide/maintain interior walls/partitions that were built with noncombustible or limited combustible materials in accordance with Section 19.1.6.3 of the 2000 Life Safety Code. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 09/23/15 at 11:50 AM, revealed a hole (approximately 3 inches) located in the Filter Room.
2. Observations and staff interviews on 09/23/15 at 11:51 AM, revealed holes(approximately 1/2 inch) located in the North Stairway.
3. Observations and staff interviews on 09/23/15 at 1:32 PM, revealed a hole (approximately 2x2 inches) located in the Basement Locker Room.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain resident room doors in proper working condition to close and latch properly into the door frame with the swing of the door closer in accordance with Section 19.3.6.3.1 of the 2000 Life Safety Code. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 09/23/15 at 11:50 AM, revealed a trash can that was being used to hold the door to Room 111 open.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 09/23/15 at 1:17 pm, revealed the door closer located on the Boiler Room Door did not operate properly when tested during this survey.
2. Observations and staff interviews on 09/23/15 at 1:30 pm, revealed the door to the Storage room located in the Basement by the stairway was not equipped with door closing hardware.
3. Observations and staff interviews on 09/23/15 at 1:35 pm, revealed the door to the storage room located by the Business Office was not equipped with self closing hardware.
4. Observations and staff interviews on 09/23/15 at 2:10 pm, revealed the self closing hardware was not functioning on the door to the Mail Room.
5. Observations and staff interviews on 09/23/15 at 2:35 pm, revealed the door closing hardware located on the door to Room 411 Film Storage Room did not operate properly when tested during this survey.
6. Observations and staff interviews on 09/23/15, revealed the door closing hardware on the doors to Rooms 405, 409 were present but were disabled and did not function properly.
7. Observations and staff interviews on 09/23/15 at 2:40 pm, revealed the door to Room CT Scan Room was not equipped with self closing hardware.
8. Observations and staff interviews on 09/23/15 at 2:44 pm, revealed the door to Room 800 HR Accounting Room was not equipped with self closing hardware.

Maintenance Staff verified these observations.

Based on observation and interview, the facility failed to maintain Stairways/Smokeproof towers in accordance with Sections 19.2.2.3, 19.2.2.4, and 7.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 09/23/15 at 11:51 AM, revealed items were being stored in the North Stairway.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain exits in smoke zones easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 09/23/15 at 1:00 pm, revealed the North Exit door in the Basement was locked using a hasp bolt locks and proper exit signs were not installed.
2. Observations and staff interviews on 09/23/15 at 2:35 pm, revealed items being stored in the corridors by the exit doors by Exam Room 2.
3. Observations and staff interviews on 09/23/15 at 3:20 pm, revealed dirty laundry containers being stored in the corridors in the North Hall. These containers were not in use.

Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide the required 90 minute annual and 30 second/30 day testing of the emergency lighting units throughout the facility as required by Sections 19.2.9.1 and 7.9 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include.
1. Observations, record review and staff interviews on 09/23/15 at 10:17 am, revealed the facility did not provide documentation of the 30 day 30 second tests and the annual 90 minute test.
2. Observations and staff interviews on 09/23/15 at 3:03 pm, revealed the emergency lights located in Room 409 did not function properly when tested during this survey.
Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide fire drills for the staff as required by Section 19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.

Findings Include:

Observations, record review and staff interviews on 09/23/15 at 11:15, revealed the facility conducted three of four day shift fire drills between 1:10 pm and 2:00 pm. It also conducted three of four evening shiff between 5:10 pm and 6:30 pm.

Maintenance Staff A verified these observations.

Based on record review/observation and interview, the facility failed to provide/maintain a sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition within the facility that was in accordance with that National Fire Protection Association (NFPA) Standard 13, Installation of Sprinkler Systems, 1999 edition and was properly interconnected with the facility ' s fire alarm system in accordance with the NFPA Standard 72, National Fire Alarm Code, 1999 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include.
Observations, record review and staff interviews on 09/23/15 at 11:10, revealed the facility failed to provide documentation of the required quarterly inspections of the facilities sprinkler system. The only documentation provided was an annual inspection which occurred on 10/22/14. No documentation was provide for the required 5 year internal inspection.
Maintenance Staff A verified these observations.

Based on observation, and interview, the facility failed to provide/maintain the building ' s sprinkler system in reliable operating condition and/or maintain proper testing and maintenance in accordance with the National Fire Protection Association (NFPA) Standard 25, Inspections, Testing, and Maintenance of Sprinkler Systems, 1998 edition, the NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1998 edition, and Sections 19.7.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 6 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 09/23/15 at 1:10 pm, revealed a dirty sprinkler head located in Room 134.
2. Observations and staff interviews on 09/23/15 at 1:40 pm, revealed the Elevator Maintenance Room did not have sprinkler coverage.
Maintenance Staff A verified these observations.