HospitalInspections.org

Based on observations, the facility failed to meet minimum building construction requirements. This affects 3 of 12 smoke zones and 12 of 25 residents. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed the following:

1. There were large holes in the ceiling tiles in the Electrical Room by Room 120.

2. There was a 1/2 inch penetration around the sprinkler head in the Nurses Locker Room.

3. There was a 1/2 inch penetration around the sprinkler head in the Pharmacy.

4. There was a 1/2 inch penetration around the sprinkler head in the Nurses Education Room.

5. There was numerous ceiling tiles missing in the IT Room.

6. There was a 1/2 inch penetration around 2 wire bundles in the IT Room.

Based on observations, the facility failed to maintain doors to the corridor. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed there were kickdowns and manual flush bolts being used throughout the facility.

Based on observations, the facility failed to maintain smoke doors in proper working order. This affects 2 of 12 smoke zones and has the potential to affect al residents and staff. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed the smoke doors by Room 122 did not close properly or completely.

Based on observations, the facility failed to maintain egress free and clear of impediments. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed there were deadbolts on the doors to both Pharmacy Doors, the IT Room, Housekeeping Storage, and both Kitchen doors.

2. There was no sidewalk to the public way outside the Clinic's North Exit.

Based on observation, the facility failed to have 2 bulb fixtures connected to emergency power outside of all required exits. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed there was not the required 2 bulb fixtures connected to emergency power outside of the following exits: South, East, West, East 2, East 1, Clinic East, Clinic West, ER, and the Dock.

Based on record review, the facility failed to test the emergency lights throughout the building. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Record review on 3-1-11, revealed there was no evidence of the monthly (30 second) or yearly (90 minute) testing of the battery powered emergency lights.

Based on observation, the facility failed to have exit signs where required. this affects 6 of 12 smoke zones and all staff members and patients. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed there were no exit signs at the following locations: by Room 109, by Room 120, by the QIM Office, and by the Ultrasound Room.

2. Observations on 3-1-11, revealed the exit sign at the West Clinic Exit was not illuminated.

Based on record review, the facility failed to conduct fire drills and failed to conduct them at varying times. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Record review on 3-1-11, revealed the following:

1. There was no overnight shift drill conducted during the 1st quarter of 2010.

2. There was no evening shift drill conducted during the 2nd quarter of 2010.

3. There was no evening or overnight shift drill conducted during the 3rd quarter of 2010.

4. There was no day or evening shift drill conducted during the 4th quarter of 2010.

5. There were 2 overnight shift drill conducted during 2010. One was at 6:41 a.m. and the other was at 6:47 a.m.

Based on observations, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed neither fire alarm panel was labeled with the location of the power source (breaker).

2. Observations on 3-1-11, revealed that neither fire alarm breaker was locked.

3. Observations on 3-1-11, revealed that neither breaker for the fire alarm panels was labeled so that it was obvious which realer was for the fire alarm.

4. There was no detection in the room the Panel was located in in the Hospital.

5. The panel in the Hospital and the Panel in the Clinic do not properly communicate with each other.

Based on record review, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Record review on 3-1-11, revealed there had been no sensitivity test conducted on the fire alarm system in at least the last 2 years.

Based on observation, the facility failed to install a sprinkler system in accordance with National Fire Protection Association (NFPA) 13. This affects 2 of 12 smoke zones and 2 residents and 4 staff members. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed there was mixed types of sprinkler heads in Room 112 and the Pharmacy.

2. Observations on 3-1-11, revealed there was a missing escutcheon ring in the Gift Shop.

3. There was no sprinkler coverage in the Vault.

4. Observations on 3-1-11, revealed there was a missing escutcheon ring in the ER Supply Room.

Based on record review and observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Record review on 3-1-11, revealed there has been no 5 year obstruction test done on the sprinkler system since it was installed.

2. There were dirty sprinkler heads throughout the facility.

3. There was storage within 18 inches of the sprinkler head in the Aux. Storage Room.

4. There were no quarterly inspections being conducted at all on the sprinkler system.

Based on observation, the facility failed to maintain fire extinguishers in accordance with National Fire Protection Association (NFPA) 10. This affects 3 of 12 smoke zones and 25 of 25 patients. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed the following:

1. The extinguisher by the South Exit was missing the monthly checks for December of 2010 and January of 2011.

2. The extinguisher in the Radiology Area was missing the monthly checks for November of 2010, January 2011, and February 2011.

3. The extinguisher by the dock was missing from the cabinet.

4. The extinguisher in the Maintenance Office was missing the monthly checks for December 2010 and January 2011.

5. There was no yearly inspection tag on the extinguisher in the Laundry Room.

Based on observation, the facility failed to maintain the hood and duct system properly and in accordance with National Fire Protection Association (NFPA) 96. This affects all employees that work in the Kitchen. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed that there were no monthly owners checks done on the hood and duct system.

Based on observations, the facility failed to store flammable liquids properly. This affects anyone who uses the Ambulance Bay. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed there was 2 propane tanks being stored in the Ambulance Bay.

Based on observations, the facility failed to label the doors to the rooms where oxygen was in use or where oxygen is being stored. This affects the entire facility.

Findings include:

Observations on 3-1-11, revealed there was no oxygen in use or oxygen storage sign in the Oxygen Storage Room, in the Respitory Therapy Room, or in the Clinic Medication Room.

Based on observations, the facility failed to maintain electrical requirements in accordance with National Fire Protection Association (NFPA) 70. This affects 1 of 12 smoke zones and any staff members that enter the Electrical Room. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed there was an outlet cover missing in the Electrical Room by Room 120.

2. There was storage within 3 feet of the electrical panel in the Bulb Storage Room.

3. There was no Ground Fault Circuit Interrupter outlet where one is required in the Soiled Hold in the Cardiac Rehab Area.

4. There were 5 surge protectors plugged in to one another in the IT Room.

5. There was a refrigerator, coffee pot, and a microwave plugged in to a surge protector in the Eye Clinic Break Room.

6. There was a surge protector being used improperly in the Break Room.

7. There was a missing blank in panel LC in the Boiler Room.

Based on record review, this facility failed to provide a proper policy regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 8.

Findings include:

Record review of the facility's sprinkler system outage policy on 3-1-11, revealed that there was not a policy in place nor was anyone aware that one was required.

Based on record review, this facility failed to provide a proper policy regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 8.

Findings include:

Record review of the facility's fire alarm system outage policy on 3-1-11, revealed that there was not a policy in place nor was anyone aware that one was required.

Based on observations, the facility failed to meet minimum building construction requirements. This affects 3 of 12 smoke zones and 12 of 25 residents. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed the following:

1. There were large holes in the ceiling tiles in the Electrical Room by Room 120.

2. There was a 1/2 inch penetration around the sprinkler head in the Nurses Locker Room.

3. There was a 1/2 inch penetration around the sprinkler head in the Pharmacy.

4. There was a 1/2 inch penetration around the sprinkler head in the Nurses Education Room.

5. There was numerous ceiling tiles missing in the IT Room.

6. There was a 1/2 inch penetration around 2 wire bundles in the IT Room.

Based on observations, the facility failed to maintain doors to the corridor. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed there were kickdowns and manual flush bolts being used throughout the facility.

Based on observations, the facility failed to maintain smoke doors in proper working order. This affects 2 of 12 smoke zones and has the potential to affect al residents and staff. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed the smoke doors by Room 122 did not close properly or completely.

Based on observations, the facility failed to maintain egress free and clear of impediments. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed there were deadbolts on the doors to both Pharmacy Doors, the IT Room, Housekeeping Storage, and both Kitchen doors.

2. There was no sidewalk to the public way outside the Clinic's North Exit.

Based on observation, the facility failed to have 2 bulb fixtures connected to emergency power outside of all required exits. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed there was not the required 2 bulb fixtures connected to emergency power outside of the following exits: South, East, West, East 2, East 1, Clinic East, Clinic West, ER, and the Dock.

Based on record review, the facility failed to test the emergency lights throughout the building. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Record review on 3-1-11, revealed there was no evidence of the monthly (30 second) or yearly (90 minute) testing of the battery powered emergency lights.

Based on observation, the facility failed to have exit signs where required. this affects 6 of 12 smoke zones and all staff members and patients. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed there were no exit signs at the following locations: by Room 109, by Room 120, by the QIM Office, and by the Ultrasound Room.

2. Observations on 3-1-11, revealed the exit sign at the West Clinic Exit was not illuminated.

Based on record review, the facility failed to conduct fire drills and failed to conduct them at varying times. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Record review on 3-1-11, revealed the following:

1. There was no overnight shift drill conducted during the 1st quarter of 2010.

2. There was no evening shift drill conducted during the 2nd quarter of 2010.

3. There was no evening or overnight shift drill conducted during the 3rd quarter of 2010.

4. There was no day or evening shift drill conducted during the 4th quarter of 2010.

5. There were 2 overnight shift drill conducted during 2010. One was at 6:41 a.m. and the other was at 6:47 a.m.

Based on observations, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed neither fire alarm panel was labeled with the location of the power source (breaker).

2. Observations on 3-1-11, revealed that neither fire alarm breaker was locked.

3. Observations on 3-1-11, revealed that neither breaker for the fire alarm panels was labeled so that it was obvious which realer was for the fire alarm.

4. There was no detection in the room the Panel was located in in the Hospital.

5. The panel in the Hospital and the Panel in the Clinic do not properly communicate with each other.

Based on record review, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

Record review on 3-1-11, revealed there had been no sensitivity test conducted on the fire alarm system in at least the last 2 years.

Based on observation, the facility failed to install a sprinkler system in accordance with National Fire Protection Association (NFPA) 13. This affects 2 of 12 smoke zones and 2 residents and 4 staff members. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed there was mixed types of sprinkler heads in Room 112 and the Pharmacy.

2. Observations on 3-1-11, revealed there was a missing escutcheon ring in the Gift Shop.

3. There was no sprinkler coverage in the Vault.

4. Observations on 3-1-11, revealed there was a missing escutcheon ring in the ER Supply Room.

Based on record review and observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25. This affects the entire facility. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Record review on 3-1-11, revealed there has been no 5 year obstruction test done on the sprinkler system since it was installed.

2. There were dirty sprinkler heads throughout the facility.

3. There was storage within 18 inches of the sprinkler head in the Aux. Storage Room.

4. There were no quarterly inspections being conducted at all on the sprinkler system.

Based on observation, the facility failed to maintain fire extinguishers in accordance with National Fire Protection Association (NFPA) 10. This affects 3 of 12 smoke zones and 25 of 25 patients. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed the following:

1. The extinguisher by the South Exit was missing the monthly checks for December of 2010 and January of 2011.

2. The extinguisher in the Radiology Area was missing the monthly checks for November of 2010, January 2011, and February 2011.

3. The extinguisher by the dock was missing from the cabinet.

4. The extinguisher in the Maintenance Office was missing the monthly checks for December 2010 and January 2011.

5. There was no yearly inspection tag on the extinguisher in the Laundry Room.

Based on observation, the facility failed to maintain the hood and duct system properly and in accordance with National Fire Protection Association (NFPA) 96. This affects all employees that work in the Kitchen. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed that there were no monthly owners checks done on the hood and duct system.

Based on observations, the facility failed to store flammable liquids properly. This affects anyone who uses the Ambulance Bay. The facility has a capacity of 25 and a census of 8.

Findings include:

Observations on 3-1-11, revealed there was 2 propane tanks being stored in the Ambulance Bay.

Based on observations, the facility failed to label the doors to the rooms where oxygen was in use or where oxygen is being stored. This affects the entire facility.

Findings include:

Observations on 3-1-11, revealed there was no oxygen in use or oxygen storage sign in the Oxygen Storage Room, in the Respitory Therapy Room, or in the Clinic Medication Room.

Based on observations, the facility failed to maintain electrical requirements in accordance with National Fire Protection Association (NFPA) 70. This affects 1 of 12 smoke zones and any staff members that enter the Electrical Room. The facility has a capacity of 25 and a census of 8.

Findings include:

1. Observations on 3-1-11, revealed there was an outlet cover missing in the Electrical Room by Room 120.

2. There was storage within 3 feet of the electrical panel in the Bulb Storage Room.

3. There was no Ground Fault Circuit Interrupter outlet where one is required in the Soiled Hold in the Cardiac Rehab Area.

4. There were 5 surge protectors plugged in to one another in the IT Room.

5. There was a refrigerator, coffee pot, and a microwave plugged in to a surge protector in the Eye Clinic Break Room.

6. There was a surge protector being used improperly in the Break Room.

7. There was a missing blank in panel LC in the Boiler Room.

Based on record review, this facility failed to provide a proper policy regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 8.

Findings include:

Record review of the facility's sprinkler system outage policy on 3-1-11, revealed that there was not a policy in place nor was anyone aware that one was required.

Based on record review, this facility failed to provide a proper policy regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period contained all applicable information. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 8.

Findings include:

Record review of the facility's fire alarm system outage policy on 3-1-11, revealed that there was not a policy in place nor was anyone aware that one was required.