HospitalInspections.org

Based on observation and staff interview the facility fails to properly protect and maintain their hazardous areas in accordance with NFPA 101. The deficient practice would affect no patients, and all visitors and staff in 2 of 5 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

During the survey conducted on 12/28/18 the following deficiencies are noted:

1. During the survey at 10:07 AM, it is observed that there is an unsealed approximate 8" penetrations by a pipe and conduit in the front wall of the basement supply and storage room that would not resist the passage of smoke.
2. During the survey at 11:44 AM, it is observed that there is an approximate 1" penetration by data wires in the ceiling of the storage closet near exam room 2.
3. During the survey at 12:20 PM, it is observed that there are approximately 10 1" unsealed penetrations by conduit in the front wall of the basement elevator mechanical room.

Staff A was present and acknowledged findings.

NFPA Standard: NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Based upon observation and staff interview the facility is not maintaining their corridor doors in compliance with NFPA 101. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading. This deficient practice would affect no patients, and all visitors and staff in 1 of 5 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.


Findings include:

During the survey conducted on 12/28/18 the following deficiency is noted:

1. During the survey at 11:45 AM, it is observed that the corridor door to exam room 2 did not properly close and latch when tested.

Staff A was present and acknowledged the finding.

NFPA Standard: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Based on observation and staff interview the facility fails to properly maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect no patients, and all visitors and staff in 2 of 5 smoke zones. The facility has a capacity of 25 with a census of 8 at the time of the survey.

Findings include:

During the survey conducted on 12/28/18 the following deficiencies are noted:

1. During the survey at 10:59 AM, it is observed that the electrical panels in respiratory therapy are blocked by carts and equipment.
2. During the survey at 12:39 PM, it is observed that the electrical panel F in the Emergency room was blocked by a wheelchair and equipment.

Staff A was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2012 NFPA 101, 9.1.2

Based on document review and staff interview, the facility fails to conduct fire drills as required by Life Safety Code NFPA 101. This deficient practice would affect all patients, visitors, and staff in 5 of 5 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings Include:

During the survey on 12/28/18 the following deficiency is noted:

1. During document review it is observed that the last fire drill held on 2nd shift in the 3rd quarter of 2018 at 7:45 PM was held as a silent drill.

Staff A was present and acknowledged the finding.

NFPA Standard: NFPA 101 2012 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based upon observation, document review, and staff interview the facility is not inspecting and maintaining their rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other zones. This deficient practice would affect no patients, and all visitors and staff in 2 of 5 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.


Findings include:

During the survey conducted on 12/28/18 the following deficiencies are noted:

1. During the survey at 9:49 AM, it is observed that the rated door to the laundry and housekeeping office, which is hooked to the fire alarm, did not properly close and latch when tested.
2. During the survey at 10:16 AM, it is observed that the rated door G86 to the utility room, which is hooked to the fire alarm, did not properly close and latch when tested.


Staff A was present and acknowledged the findings.

NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based on staff interview and observation, the facility fails to maintain their electrical systems in accordance with NFPA 70. The deficient practice would affect no patients, and all visitors and staff in 2 of 5 smoke zones. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

During the survey conducted on 12/28/18 the following deficiencies are noted:

1. During the survey at 9:41 AM, it is observed that there is an extension cord powering a power strip in the training / education office.
2. During the survey at 10:45 AM, it is observed that there is an extension cord powering a power strip in the Director of Nursing office.

Staff A was present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2012 NFPA 101, 9.1.2