Bringing transparency to federal inspections
Tag No.: K0211
Based on observation and interview, the facility had several corridor doors that did not meet the requirements of NFPA 101 "The Life Safety Code" 2012 edition and the NFPA 80 Standard for Fire Doors and other openings Protective's 2010 edition. This deficient practice could affect 18 of 18 residents, as well as an undetermined number of staff, and visitors if smoke from a fire were allowed to enter the exit access corridors making it untenable.
Findings include:
During documentation review between 1:30 pm and 5:30 PM on 03/19/2018, during documentation review, the facility had not completed the fire door inspection for all of the fire rated doors located throughout the facility, the documentation did not include the fire rated stairwell doors.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0321
Based on observation and staff interview the facility failed to construct 2 soiled utility rooms in accordance with the 2012 Life Safety Code, (NFPA 101) section 19.3.2.1.3. This deficient practice could allow for smoke or fire to enter the corridor making it untenable for exiting, affecting an undetermined amount of patients, staff and visitors.
Findings include:
On the facility tour between 08:00 am and 11:00 pm on 03/20/2018 observations and staff interview revealed:
1) Transfer ducts in the first floor shell space were left open.
2) Soiled utility room in the dialysis department not rated.
3) Storage room in dialysis does not have a door closure.
4) Storage room 243 did not have a door closure.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0324
Based on a review of documentation and an interview with staff, it was determined that the kitchen hood suppression system is not in accordance with NFPA 101 The Life Safety Code (edition 2012), Cooking equipment is protected in accordance with NFPA 96. This could affect all patients and an undetermined amount of staff and visitors.
Findings Include:
On the facility tour between 8:00 am to 11:00 am on 03/20/2018 , observations revealed that the maintenance on the hood suppression system was last completed in March 6, 2017.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0346
Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the Fire Alarm system has to be placed out-of-service for four or more hours in a 24 hour period as per NFPA 101 2012 edition section 9.6.1.6. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all 25 patients as well as an undetermined number of staff, and visitors.
Findings include:
On the facility tour between 1:30 pm to 5:30 pm on 03/19/2018 record review and staff interview revealed the fire alarm out of service policy did not contain a statement stating that a fire watch shall be conducted if the fire alarm is out of service for more than 4 hours in a 24 hour period and the person who is doing the fire watch will perform only the job of fire watch and will have no other assigned duties.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0353
Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the 2012 Life Safety Code (NFPA 101) and NFPA 25 section 5.3.2 & 14.2. The standard for testing and maintenance of sprinkler systems. This deficient condition could cause the sprinkler system not to function properly and allow for the spread of fire. This could affect all of the 25 patients and an undetermined amount of staff and visitors.
Findings include:
On the facility tour between 8:00 am to 11:00 pm on 03/20/2018 documentation review revealed:
1) 2 Sprinkler Heads are too close to the wall in Radiology.
2) Sprinkler Heads 3" inside of clinic.
3) Ceiling Tiles have 3" hole in the laundry room.
3) Quarterly testing of the sprinkler system was not documented.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0354
Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for ten or more hours in a 24 hour period as per NFPA 25. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all 25 patients as well as an undetermined number of staff, and visitors to the facility .
Findings include:
On the facility tour between 1:30 pm to 5:30 pm on 03/19/2018 record review and staff interview revealed the fire Sprinkler out of service policy did not contain a statement stating that a fire watch shall be conducted if the fire sprinkler system is out of service for more than 10 hours in a 24 hour period and the person who is doing the fire watch will perform only the job of fire watch and will have no other assigned duties.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0372
Based on observation and staff interview the facility failed to maintain a smoke barrier as required by the 2012 Life Safety Code (NFPA 101) section 19.3.7.3, 8.8.7.1 (1). This deficient practice could allow smoke to transfer from one smoke compartment to another affecting the exiting of all patients, staff and visitors.
Findings include:
On the facility tour between 8:00 am to 11:00 am on 03/20/2018 observations and staff interview revealed penetrations without the proper fire stopping above the ceiling of the smoke barrier adjacent to the clinic in the following areas.
1. 3" Conduit penetration above ceiling at infusion therapy door above ceiling on the second floor.
2. 3" Conduit penetration and 2' Copper pipe on second floor by surgery doors.
3. 4' hole in smoke barrier next to ER waiting room.
4. IT & Electrical Room there are penetrations in 1 hour wall in the back of the ER.
5. Penetrations in smoke barrier wall on the first floor by clinical information.
6. Hole above cross corridor door smoke barrier on the second floor by the nursery.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0521
Based on observation and a staff interview, it could not be verified whether the facility's general ventilating and air conditioning system (HVAC) was maintained in accordance with NFPA 101 (2000) Chapter 19, Section 19.5.2.1 and Chapter 9, Section 9.1 and NFPA 90A. In a fire emergency, a noncompliant HVAC system could adversely affect all residents.
FINDINGS INCLUDE:
On 03/19/2018 during the documentation review with facility staff, it was confirmed the HVAC system does contain one or more fire/smoke dampers, however, no fire/smoke dampers documentation could be located that they were inspected and tested within the previous 6 years, in accordance with NFPA 90A Chapter 3.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0711
Based on documentation review and staff interview, the facility failed to provide a written fire safety plan that addressed all of the items required by NFPA 19.7.2.2.This deficient practice could affect 25 of 25 patients.
Findings include:
During documentation review on 03/19/2018, all 9 required items could not be found in the evacuation and relocation plan provided at the time of the survey.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0712
Based on record review and staff interview the facility failed to provide documentation of fire drills at least quarterly on each shift as required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all 25 patients and an undetermined amount of staff and visitors.
Findings include:
On facility tour between 8:00 AM and 10:00 AM on 03/20/2018, documentation reviewed revealed that fire drills were not properly documented for the last 12 months. The DACT System was not tested on a monthly basis.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0901
Based on documentation review and staff interview, the facility failed to inspect the building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. The deficient practice could affect all patients.
Findings include:
During documentation review between on 03/19/2018, documentation review and staff interview revealed the required risk assessment NFPA 99 had not been started at the time of the survey.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0912
Electrical Systems - Receptacles
Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed.
6.3.2.2.6.2 (F), 6.3.2.4.2 (NFPA 99) This deficient practice could affect 25 of 25 Patients.
Findings include:
During documentation review on 03/19/2018, documentation could not be located to show that an electrical outlet inspection had occurred throughout the facility.
This deficient condition was confirmed by the Director of Maintenance.
Tag No.: K0914
Based on observations and staff interview, that the electrical testing and maintenance was not maintained in accordance with NFPA 99 Standards for Health Care Facilities 2012 edition, section 6.3.3.2.4. This could negatively affect 25 of 25 patients as well as an undetermined number of staff, and visitors to the facility.
Findings include:
During documentation review on 03/19/2018, documentation could not be located to show that an electrical outlet inspection had occurred throughout the facility.
This deficient condition was confirmed by the Director of Maintenance.