HospitalInspections.org

Based on observation and interview, it was determined that the facility was a one story building consisting of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to maintain minimum building construction requirements by ensuring that gaps around penetrations were sealed with fire rated materials. This deficient practice affects approximately 6 staff. This facility has a capacity of 25 and a census of 3.

Findings include:

1. Observation and interview on 06/08/15 at 11:27 a.m., revealed a 1/2" gap around duct work that penetrated the wall near the ceiling along the south wall of Air Handler Room #1.

2. Observation and interview on 06/08/15 at 11:27 a.m., revealed 1/2" gaps between the south wall and ceiling of Air Handler Room #1. The Plant Operations Manager verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain the buildings exit signs in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 Edition. This deficient practice affects approximately 4 staff within the facility. This facility has a capacity of 25 and a census of 3.
Findings include:
Observation and interview on 06/08/15 at 11:19 a.m., revealed the exit sign near the exterior exit in the Boiler Room failed to illuminate when tested. The Plant Operations Manager verified this observation at the time of the survey process.

Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice affects all occupants, 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 3.

Findings include:

Record review and interview on 06/08/15 at 10:20 a.m., revealed the facility failed to conduct a night shift drill for the fourth quarter of 2014. The Plant Operations Manager verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 Edition. This deficient practice would affect all occupants in the facility. This facility has a capacity of 25 and a census of 3.

Findings include:

Record review and interview on 06/08/15 at 10:28 a.m., revealed the facility did not complete a required semi-annual inspection of the fire alarm system. The Plant Operations Manager verified this observation at the time of the survey process.

Based on observation, interview, and record review the facility is not ensuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 Edition. This deficient practice affects all occupants in the facility. This facility has a capacity of 25 and a census of 3.

Findings include:

1. Observation and interview on 06/08/15 at 11:44 a.m., revealed the smoke detector in the corridor near Outpatient Treatment Center Room #101 was within three feet of an air diffuser.

2. Record review and interview on 06/08/15 at 1:15 p.m., revealed the facility failed to conduct the required biennial sensitivity testing of the fire alarm system. The Plant Operations Manager verified these observations at the time of the survey process.

Based on observation, interview, and record review, the facility failed to maintain the buildings emergency generator in accordance with National Fire Protection Association (NFPA) 110, 1999 Edition. This deficient practice affects all occupants in the facility. This facility has a capacity of 25 and a census of 3.

Findings include:

1. Record review and interview on 06/08/15 at 10:02 a.m., revealed the facility failed to conduct monthly testing of the emergency generator for the month of August 2014.

2. Observation and interview on 06/08/15 at 11:12 a.m., revealed the manual emergency shut off for the generator was located inside the generator panel. The manual shut off should be located a safe distance away from the generator and labeled. The Plant Operations Manager verified these observations at the time of the survey process.

Based on observation and interview, 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. This deficient practice would place residents, staff, and visitors at risk in the event of a fire. This facility has a capacity of 25 and a census of 3.

Findings Include:

1. Observation and interview on 06/08/15 at 11:17 a.m., revealed an open electrical junction box along the ceiling near the interior entrance to the Boiler Room.

2. Observation and interview on 06/08/15 at 11:23 a.m., revealed an open electrical junction box above the main hospital disconnect in the Main Electrical Room.

3. Observation and interview on 06/08/15 at 11:55 a.m., revealed a surge protector was being used to supply power to a coffee pot in the Nurse's Lounge.

4. Observation and interview on 06/08/15 at 12:12 p.m., revealed a surge protector was being used to supply power to a fan and a refrigerator in the ER Provider Lounge.

5. Observation and interview on 06/08/15 at 12:57 p.m., revealed a surge protector was being used to supply power to a toaster and a coffee pot in the Health Information Management Office. The Plant Operations Manager verified these observations at the time of the survey process.