HospitalInspections.org

Based on observation and staff interview, this facility is not providing appropriate construction standards as required by the Life Safety Code. This facility is a one-story building composed of protected non-combustible construction (concrete and steel) and has an area with unprotected steel beams, in violation of NFPA 101, 19.1.6.2. This deficient practice affects all occupants of the building. This facility is certified for 25 beds and had a census of 7.

Findings include:

Observation and staff interview on 6/23/14, the facility was observed to be a one-story building composed of protected non-combustible construction (concrete and steel). The following areas contained exposed beams:
1. The abulance bay had exposed red steel that the fire retardant spray had fallen off due to the garage door beam.
2. The loading dock ceiling beam (2 inch by 4 inch) was missing fire retardant spray.
Maintenance Staff verified these observations during the survey process.

Based on observation and staff interview, the facility is not providing doors to the corridor that stay latched tightly within the doorframes. This deficient practice would not prevent the spread of smoke, affecting all occupants in two of nine smoke zones. This facility is certified for 25 beds with a census of 7.

Findings include:

1. Observation and staff interview on 6/23/14, revealed the door to the Electrical Room (D131A) would not latch properly into the frame due to the self-closing device. Maintenance Staff confirmed this observation during the survey process.

2. Observation and staff interview on 6/23/14, revealed the Kitchen corridor door (D05A) did not close latch properly into the frame due to the self-closing device. Maintenance Staff verified this observation during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of nine smoke compartments. This facility is certified for 25 beds and had a census of 7.

Findings include:

Observation and staff interview on 6/23/14, the facility failed to provide separation for the following areas;
1. In the Basement Mechanical Room (F01A) above the door there was 1/2 inch conduit penetration.
2. In the Basement Mechanical Room (F01A) East wall behind the HVAC duct there was a 6 inch hole.
3. In the Basement Mechanical Room (F01A) there was 1/2 inch penetration surrounding a sprinkler pipe located above the pressure tank.
4. In the Basement Receiving Room the double doors and wall to the corridor do not meet the one-hour rating.
5. In Room (B02A) (Southwest wall) there was a 1/2 inch penetration surrounding a 1 1/2 inch copper pipe.
Maintenance Staff verfied these observations during the survey process.

Based on record review and staff interview, the facility could not provide emergency plans and procedures. This deficient practice effects all occupants including staff, visitors and patients, as this can affect the abilities of the staff to respond in the event of an actual emergency. This facility is certified for 25 beds and had a census of 7.

Findings include:

Review of the facility's records and staff interview on 6/23/14, revealed that the facility could not provide their emergency plans and procedures during a fire emergency drill. Maintenance Staff verified this observation during the survey process.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility is certified for 25 beds and had a census of 7.

Findings include:

Review of the facility's fire drill records and staff interview on 6/23/14, revealed the facility was missing a 2nd shift drill for the third quarter and missing a 1st shift drill for fourth quarter in 2014. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return and could affect all occupants of the building. This facility is certified for 25 beds and had a census of 7.

Findings include:

Observation and interview on 6/23/14, revealed throughout the facility they had air supplies within three feet of the smoke detectors. Maintenance Staff verified these observations during the survey process.

Based on record review and interview, the facility failed to provide paperwork for the semi-annual inspection reports of the building's fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition, NFPA Standard 70, National Electrical Code, 1999 edition, and Section 9.6.1.4 of the NFPA Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect all patients within the facility.
Findings include:
The record review and interview on 6/25/14, revealed no fire alarm testing paperwork was available at the time of the inspection. Staff confirmed this observation during the survey process.

(A)
Based on observation, staff interview, and record review, the facility failed to provide documentation of the complete automatic sprinkler system. All smoke compartments, patients, and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Observation, staff interview and during the record review of the facilities fire safety components on 6/23/14, revealed the sprinkler system paperwork was not available at the time of the survey. Maintenance Staff confirmed this observation during the survey process.


(B)
Based on observation and staff interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all one of seven smoke zones. The facility is certified for 25 beds and a census of 7 at the time of survey.

Findings include:

Observation and staff interview on 6/23/14, revealed the shelves installed in the Storage room (D133A) were not installed 18 inches below the sprinkler head. Maintenance Staff verified this observation during the survey process.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments of building and all of the patients and staff. The facility has 25 certified beds and at the time of the survey the facility census was 7.

Findings include:

Documentation review and staff interview on 6/23/14 with Maintenance Staff revealed that documentation was missing of the generator monthly testing for May 2014 and weekly inspections for three weeks in June 2014. Maintenance Staff verified these observations during the survey process.

Based on observation and staff 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, placing the Staff and Patients of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 7 at the time of the survey.

Findings Include:

Observation and staff interview on 6/23/14, revealed the facility failed to maintain the electrical system in the following areas:
1. In the PT room there was a missing cover plate for the electrical junction box located on the ceiling.
2. In the Basement Mechanical Room (E52A) there was a missing cover plate for the electrical junction box located on the wall.
3. In the Basement by the Materials Management door was a missing cover plate for the electrical junction box located on the East wall.
Maintenance Staff verified these observations during the survey process.

Based on observation and staff interview, this facility is not providing appropriate construction standards as required by the Life Safety Code. This facility is a one-story building composed of protected non-combustible construction (concrete and steel) and has an area with unprotected steel beams, in violation of NFPA 101, 19.1.6.2. This deficient practice affects all occupants of the building. This facility is certified for 25 beds and had a census of 7.

Findings include:

Observation and staff interview on 6/23/14, the facility was observed to be a one-story building composed of protected non-combustible construction (concrete and steel). The following areas contained exposed beams:
1. The abulance bay had exposed red steel that the fire retardant spray had fallen off due to the garage door beam.
2. The loading dock ceiling beam (2 inch by 4 inch) was missing fire retardant spray.
Maintenance Staff verified these observations during the survey process.

Based on observation and staff interview, the facility is not providing doors to the corridor that stay latched tightly within the doorframes. This deficient practice would not prevent the spread of smoke, affecting all occupants in two of nine smoke zones. This facility is certified for 25 beds with a census of 7.

Findings include:

1. Observation and staff interview on 6/23/14, revealed the door to the Electrical Room (D131A) would not latch properly into the frame due to the self-closing device. Maintenance Staff confirmed this observation during the survey process.

2. Observation and staff interview on 6/23/14, revealed the Kitchen corridor door (D05A) did not close latch properly into the frame due to the self-closing device. Maintenance Staff verified this observation during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of nine smoke compartments. This facility is certified for 25 beds and had a census of 7.

Findings include:

Observation and staff interview on 6/23/14, the facility failed to provide separation for the following areas;
1. In the Basement Mechanical Room (F01A) above the door there was 1/2 inch conduit penetration.
2. In the Basement Mechanical Room (F01A) East wall behind the HVAC duct there was a 6 inch hole.
3. In the Basement Mechanical Room (F01A) there was 1/2 inch penetration surrounding a sprinkler pipe located above the pressure tank.
4. In the Basement Receiving Room the double doors and wall to the corridor do not meet the one-hour rating.
5. In Room (B02A) (Southwest wall) there was a 1/2 inch penetration surrounding a 1 1/2 inch copper pipe.
Maintenance Staff verfied these observations during the survey process.

Based on record review and staff interview, the facility could not provide emergency plans and procedures. This deficient practice effects all occupants including staff, visitors and patients, as this can affect the abilities of the staff to respond in the event of an actual emergency. This facility is certified for 25 beds and had a census of 7.

Findings include:

Review of the facility's records and staff interview on 6/23/14, revealed that the facility could not provide their emergency plans and procedures during a fire emergency drill. Maintenance Staff verified this observation during the survey process.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility is certified for 25 beds and had a census of 7.

Findings include:

Review of the facility's fire drill records and staff interview on 6/23/14, revealed the facility was missing a 2nd shift drill for the third quarter and missing a 1st shift drill for fourth quarter in 2014. Maintenance Staff verified this observation during the survey process.

Based upon record review and interview, the facility failed to provide paperwork for the fire drills as required by Section A.19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire.

Findings include:

Record review and interview on 6/25/14, revealed the facility failed to provide fire drill documentation. Staff verified this observation during the survey process.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return and could affect all occupants of the building. This facility is certified for 25 beds and had a census of 7.

Findings include:

Observation and interview on 6/23/14, revealed throughout the facility they had air supplies within three feet of the smoke detectors. Maintenance Staff verified these observations during the survey process.

Based on record review and interview, the facility failed to provide paperwork for the semi-annual inspection reports of the building's fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition, NFPA Standard 70, National Electrical Code, 1999 edition, and Section 9.6.1.4 of the NFPA Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect all patients within the facility.
Findings include:
The record review and interview on 6/25/14, revealed no fire alarm testing paperwork was available at the time of the inspection. Staff confirmed this observation during the survey process.

(A)
Based on observation, staff interview, and record review, the facility failed to provide documentation of the complete automatic sprinkler system. All smoke compartments, patients, and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 7.

Findings include:

Observation, staff interview and during the record review of the facilities fire safety components on 6/23/14, revealed the sprinkler system paperwork was not available at the time of the survey. Maintenance Staff confirmed this observation during the survey process.


(B)
Based on observation and staff interview, the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. This deficient practice affects all one of seven smoke zones. The facility is certified for 25 beds and a census of 7 at the time of survey.

Findings include:

Observation and staff interview on 6/23/14, revealed the shelves installed in the Storage room (D133A) were not installed 18 inches below the sprinkler head. Maintenance Staff verified this observation during the survey process.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments of building and all of the patients and staff. The facility has 25 certified beds and at the time of the survey the facility census was 7.

Findings include:

Documentation review and staff interview on 6/23/14 with Maintenance Staff revealed that documentation was missing of the generator monthly testing for May 2014 and weekly inspections for three weeks in June 2014. Maintenance Staff verified these observations during the survey process.

Based on observation and staff 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, placing the Staff and Patients of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 7 at the time of the survey.

Findings Include:

Observation and staff interview on 6/23/14, revealed the facility failed to maintain the electrical system in the following areas:
1. In the PT room there was a missing cover plate for the electrical junction box located on the ceiling.
2. In the Basement Mechanical Room (E52A) there was a missing cover plate for the electrical junction box located on the wall.
3. In the Basement by the Materials Management door was a missing cover plate for the electrical junction box located on the East wall.
Maintenance Staff verified these observations during the survey process.