HospitalInspections.org

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of five smoke compartments. This facility has a capacity of 25 and a census of 5 patients.

Findings include:

1. Observation of the Store Room on 4/20/11, revealed that the door was not equipped a self-closing device.
2. Observation of the Boiler Room on 4/20/11, revealed the west wall contained two pipe penetrations 1/2 inch in size.

Based on record review, the facility is not conducting fire drills at least quarterly 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 5 patients.

Findings include:

Review of the facility's fire drill records on 4/20/11, revealed that fire drills in the 3rd quarter of 2010 were missing a day shift drill.

Based on observation, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The census was 25 with a capacity of 5.

Findings include:

Observation on 4/20/11, revealed the sprinkler heads in the following locations contained paint: Time Clock Room and Bone Scan Room.

Based on record review, the facility failed to maintain the documentation for the emergency generator power supply as required. The deficient practice would affect all smoke compartments, all of the patients and staff. The facility has 25 certified beds and at the time of the survey the facility census was 5.

Findings include:

Record review on 4/20/11, revealed that the documentation of the generator run times had not been maintained. Documentation did not show the start and end run times.

Based on observation, 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 5 patients at the time of the survey.

Findings Include:

Observations on 4/20/11, revealed the facility failed to provide Ground Fault Circuit Interrupter electrical outlets in the wash station area of the Kitchen.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of five smoke compartments. This facility has a capacity of 25 and a census of 5 patients.

Findings include:

1. Observation of the Store Room on 4/20/11, revealed that the door was not equipped a self-closing device.
2. Observation of the Boiler Room on 4/20/11, revealed the west wall contained two pipe penetrations 1/2 inch in size.

Based on record review, the facility is not conducting fire drills at least quarterly 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 5 patients.

Findings include:

Review of the facility's fire drill records on 4/20/11, revealed that fire drills in the 3rd quarter of 2010 were missing a day shift drill.

Based on observation, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire. The census was 25 with a capacity of 5.

Findings include:

Observation on 4/20/11, revealed the sprinkler heads in the following locations contained paint: Time Clock Room and Bone Scan Room.

Based on record review, the facility failed to maintain the documentation for the emergency generator power supply as required. The deficient practice would affect all smoke compartments, all of the patients and staff. The facility has 25 certified beds and at the time of the survey the facility census was 5.

Findings include:

Record review on 4/20/11, revealed that the documentation of the generator run times had not been maintained. Documentation did not show the start and end run times.

Based on observation, 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 5 patients at the time of the survey.

Findings Include:

Observations on 4/20/11, revealed the facility failed to provide Ground Fault Circuit Interrupter electrical outlets in the wash station area of the Kitchen.