HospitalInspections.org

Based on observations, record review and staff interview, the facility failed to comply with NFPA 80, Standard for Fire Doors and Other Opening Protective's 2010 edition. This deficient practice could affect the exiting ability of an undetermined amount of patients, staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 documentation review revealed there was no record of fire door inspections per NFPA 101, 7.2.1.15.2

This deficient condition was confirmed by the Director of Environmental Services.

Based on observations and staff interview the facility failed to properly identify an exit door in the path of egress as required in The Life Safety Code NFPA 101 2012 edition section 7.10.5.1. This deficient condition could affect the exiting of an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 observations revealed the exit sign on the 2nd floor adjacent to room 232 was not illuminated.

This deficient condition was confirmed by the Director of Environmental Services

Based on observation and staff interview the facility to maintain several hazardous storage rooms in accordance with the 2012 Life Safety Code (NFPA 101) section 19.3.2.1.3. This deficient condition could allow smoke or fire to enter the corridor making it untenable and affect the quick and efficient exiting for an undetermined amount of patients, staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 observations revealed the following.

1. Holes in the ceiling of the storage room on the first floor adjacent to the elevator.
2. A storage room on the first floor in the maintenance hall with a conduit penetrating the wall without being properly fire stopped.
3. Three combustible storage rooms on the second floor over 50 sq ft, room 227, next to room 244 and next to room 243 without self closing doors.

This deficient condition was confirmed by the Director of Environmental Services.

Based on documentation review and staff interview the facility failed to inspect the cooking equipment, every six months, as stated in the Life Safety Code (NFPA 101) 2012 edition section 9.2.3 & NFPA 96 section 11.2. This deficient practice could allow for the spread of fire if the hood suppression system did not operate properly, affecting an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 08/20/2018 documentation review revealed only one hood inspection report in the last 12 months.

This deficient condition was confirmed by the Director of Environmental Services.

Based on observations and staff interview the facility failed to install the fire alarm system in accordance with NFPA 101 Life Safety Code (2012) section 19.3.4.1, 9.6.1.3 and NFPA 72 National Fire Alarm Code (2010) . This deficient practice could affect the ability of the alarm system to properly notify all patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018,

1. Observations revealed a fire alarm notification appliance connected to a power source laying above the corridor ceiling tile at the intersection of the maintenance hall and the main corridor of the 1949 addition.
2. Observations revealed a smoke detector connected to a power source laying above the corridor ceiling tile across from the pharmacy.

This deficient condition was confirmed by the Director of Environmental Services.

Based on record review and staff interview the facility failed to verify the DACT signal as required by the Life Safety Code,(LSC) 2012 edition, section 9.6.1.3 and NFPA 72, The National Fire Alarm and Signaling Code, 2010 edition, table 14.3.1. This deficient condition could delay alarm notification to emergency personnel in case of a failure and affect all patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 documentation review revealed there was no record of the DACT being tested in the 3rd & 4th quarter of 2017 and the 1st & 3rd shift of the 1st quarter and the 3rd shift of the 2nd quarter of 2018.

This deficient condition was confirmed by the Director of Environmental Services.

Based on observations and staff interview the facility failed to install the smoke detection in accordance with NFPA 101 Life Safety Code, (2012) section 19.3.6.1 and NFPA 72 National Fire Alarm Code (2010) section 17.6.3.1.1 This deficient practice could affect the ability of the alarm system to sound in a timely manner during a fire event which could affect 10 of the 21 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 observations revealed a smoke detector was not installed in the lounge area open to the corridor at the NE end of the corridor in the 1971 addition.

This deficient condition was confirmed by the Director of Environmental Services.

Based on observation and staff interview the facility failed to install sprinkler heads in accordance with the 2012 edition of the Life Safety Code (NFPA 101) sections 19.3.5.1, 9.7.1.1 and the 2010 edition of NFPA 13, The Standard for the Installation of Sprinkler Systems. This deficient practice could cause a delay in extinguishing a fire affecting the safety of 10 of the 46 residents and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 observations revealed a sprinkler head in the IT office did not extend through the ceiling tile.

This deficient condition was confirmed by the Director of Environmental Services.

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 5.2.1.1.2. 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 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 on 08/20/2018 the following was revealed.

A. Documentation review revealed the quarterly flow tests did not contain flow pressures.

B. Observations revealed ceiling tiles missing in the following locations.
1. A hazardous storage room in the Central storage area.
2. On the second floor in the housekeeping closet.
3. In the 2nd floor storage room #234.
4. In the oxygen storage room by x-ray.

C. Observations revealed :
1. A 1 1/2 " x 5" hole in the ceiling tile in room 109 of the 1971 addition.
2. An escutcheon missing from a sprinkler head in the 2nd floor break room.
3. Stored items blocking the sprinkler head in the PT store room

This deficient condition was confirmed by the Director of Environmental Services.

Based on observation and staff interview the facility failed to provide documentation of the required annual fire extinguisher inspections as required by the Life Safety Code, NFPA 101 2012 edition section 9.7.4.1 and NFPA 10, Portable Fire Extinguishers, sections 7.3.1.1.1 & 7.2.4.4. This deficient practice could render an extinguisher inoperable and affect all patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 08/20/2018 documentation review revealed there was no record of an annual fire extinguisher inspection.

This deficient condition was confirmed by the Director of Environmental Services.

Based on observation and staff interview the facility failed to maintain the fire resistance of corridor walls in accordance with the Life Safety Code (NFPA 101) 2012 edition section 19.3.6.2.2. This deficient practice could allow for the spread of smoke and fire making the corridor untenable for exiting, affecting an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 observations revealed a 2" diameter hole and a 1 1/2" x 4" hole in the corridor wall of the oxygen storage room by x-ray.

This deficient condition was confirmed by the Director of Environmental Services.

Based on observation and staff interview the facility failed to provide a storage room with corridor doors that are suitable for resisting the passage of smoke in accordance with the 2012 Life Safety Code (NFPA 101) section 19.3.6.3.1 & 19.3.6.3.5. This deficient practice could allow for smoke to enter the corridor making it difficult to exit in the case of fire, affecting 10 of the 21 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 08/20/2018 observations revealed combustibles being stored in a space across from the nurses station in the 1971 addition with doors (bifold) that cannot resist the passage of smoke.

This deficient condition was confirmed by the Director of Environmental Services.

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 an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 observations revealed a one inch diameter hole in the smoke barrier above the ceiling line at the intersection of the maintenance hall and the main corridor of the 1949 building.


This deficient condition was confirmed by the Director of Environmental Services

Based on document review and staff interview, the facility did not maintain the heating, ventilation, and air conditioning in accordance with the 2012 LSC NFPA 101 9.2, 19.5.2.1 and NFPA 90A. This deficient practice could effect all patients and an undetermined amount of staff and visitors.

Findings include:

On a facility tour between 8:00 am to 3:00 pm on 08/20/2018, document review revealed that the facility could not provide evidence of smoke and fire damper testing being conducted within the past 6 years.


This deficient practice was confirmed by the Director of Environmental Services.

Based on record review and staff interview the facility failed to maintain a Fire Safety Plan as required in NFPA 101 Life Safety Code, 2012 edition section 19.7.2.2. This deficient practice could cause confusion in an emergency and affect all 21 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 08/20/2018 documentation review revealed the fire safety plan did not address item 2, the transmission of alarm to the fire department and item 3, a call to the fire department.


This deficient practice was confirmed by the Director of Environmental Services.

Based on record review and staff interview the facility failed to conduct 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 21 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 documentation review revealed there was no record of fire drills in the 3rd & 4th quarter of 2017, 1st & 3rd shift of the 1st quarter and 3rd shift of the 2nd quarter in 2018.

This deficient practice was confirmed by the Director of Environmental Services.

Based on observation and staff interview, the facility has failed to provide a complete and current facility Risk Assessment in accordance with the NFPA 99 "Health Care Facilities Code" 2012 edition section 4.1. This deficient practice could affect all patients, as well as an undetermined number of staff, and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 during record review the facility was not able to provide a risk assessment document based on NFPA 99.

This deficient practice was confirmed by the Director of Environmental Services.

Based on documentation review and staff interview the facility failed to provide a maintenance program for the gas and vacuum system as required by NFPA 99, Health Care Facilities Code 2012 edition section 5.1.14.2.1 &2. This deficient practice could negatively affect all patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 on 06/20/2018 documentation review revealed there was no record of a piped gas and vacuum maintenance program.

This deficient practice was confirmed by the Director of Environmental Services.

Based on documentation review and staff interview the facility failed to provide an inspection program for the gas and vacuum system as required by NFPA 99, Health Care Facilities Code 2012 edition section 5.1.14.2.1 &2. This deficient practice could negatively affect all patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 on 06/20/2018 documentation review revealed there was no record of a piped gas and vacuum inspection program.

This deficient practice was confirmed by the Director of Environmental Services.

Based on record review and staff interview the facility failed to provide complete test documentation in accordance with the 2012 edition of the Life Safety Code (NFPA 101) section 9.1.3.1 and the 2010 edition of NFPA 110 the Standard for Emergency and Standby Power Systems. This deficient practice could affect the safety of an undetermined amount of staff and visitors and all of the 21 patients if the generator failed to operate during a power outage.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 documentation review revealed there was no record of weekly inspections and monthly tests for 4 of the last 12 months.

This deficient practice was confirmed by the Director of Environmental Services

Based on observation and staff interview the facility failed to ensure extension cords are used in accordance with the 2012 edition of NFPA 99 section 10.2..4.2. & 400-8 (NFPA 70), 590.3(D) (NFPA 70), This deficient practice could affect and an undetermined amount of patients, staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 observations revealed an extension cord being used to provide permanent power to a light in the pharmacy.

This deficient practice was confirmed by the Director of Environmental Services.

Based on observation and staff interview the facility failed to store oxygen tanks in accordance with NFPA 99 (Health Care Facilities Code) 2012 edition section 5.1.3.3.2 & 11.3 and This deficient practice could create an oxygen filled atmosphere and accelerate the spread of fire. This condition could affect an undetermined amount of patients,staff and visitors.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 06/20/2018 observations revealed the oxygen bottles being stored in the O2 room next to X-ray were not labeled full or empty and the med gas room door in the maintenance hall did not have a 60 minute door.

This deficient practice was confirmed by the Director of Environmental Services.