HospitalInspections.org

Based on observation and interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly in their frames. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview on 10/14/14, revealed a door wedge propping the door open to the Staff Lounge in the Clinic. Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview on 10/14/14, revealed the corridor door to the Dirty B Utility Room did not close and latch properly when tested. Maintenance Staff A verified this observation.

Based on observation and interview, the facility is not providing an all-weather surface from each exit to a public way (an area of safety). This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

1. Observation and interview on 10/14/14, revealed the exit door located by the Administrator's Office has a square cement pad directly outside the door with no sidewalk leading to a public way.
2. Observation and interview on 10/14/14, revealed the exit door located by the Employee Break Room has a square cement pad directly outside the door with no sidewalk leading to a public way.


Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not ensuring that patient room doors and other doors are arranged such that they can opened from inside without the use of a key or special knowledge. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview on 10/14/14, revealed several patient room doors and some office doors were equipped with a deadbolt lock that did not release with a single action turn of the door handle. Maintenance Staff A verified these observations.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift as required. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 patients and a census of 9.

Findings include:

1. Record review and staff interview on 10/14/14, revealed the facility failed to perform fire drills in the 2nd quarter on both first and third shifts and on the third shift on the 4th quarter.
2. Record review and staff interview on 10/14/14, revealed the facility is not varying the fire drill times on each shift. Half of the fire drills documented were between the hours of 1520 and 1600.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide a properly tested and maintained fire alarm system in accordance with National Fire Protection Association (NFPA) 72. The entire facility is directly affected by this deficient practice. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview of the facility's fire alarm inspection documentation on 10/14/14, revealed that the facility is not have the fire alarm system tested/inspected as required by code. The fire alarm system has not been inspected by General Fire and Safety since 6/13/12. Maintenance Staff A verified this observation.

Based on observation, interview and record review, the facility failed to maintain and test smoke detectors for sensitivity in accordance with National Fire Protection Association (NFPA) 72, 7-3.2.1. All smoke detectors throughout the building were affected and all occupants of the building could be affected by this deficient practice. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation, interview and record review on 10/14/14, revealed the facility did not have a sensitivity test performed on their smoke detectors every other year as required. There was no documentation on file to verify when the last sensitivity test had been performed. Maintenance Staff A verified this observation.

Based on record review, interview, and observation, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments and all occupants could be affected by this deficient practice. This facility has 25 licensed beds and at the time of the survey the census was 9.

Findings include:

During record review, interview and observation of the facility's fire safety components on 10/14/14, revealed the absence of documentation to indicate that quarterly inspections of the sprinkler system had been performed. Maintenance Staff A stated that he thought they were being performed by Continental.

Based on observations and interview the facility failed to provide combustible decorations that are flame retardant. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

1. Observation and interview on 10/14/14, revealed the door to Room 210 (office) in the Clinic had the door wrapped in toilet paper.
2. Observation and interview on 10/14/14, revealed a door in the Front Entrance Waiting Area had the door wrapped in toilet paper.

Maintenance Staff A verified these observations.

Based on observation and 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. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

1. Observation and interview on 10/14/14, revealed a missing junction box cover above the lay-in ceiling tile located above the door in the Soiled Linen Room in the Basement.
2. Observation and interview on 10/14/14, revealed two missing blanks in electrical panel LP3 located in the Boiler Room.
3. Observation and interview on 10/14/14, revealed a brown extension cord being used for decorative lights in Room 210 (office) in the Clinic.
Observation and interview on 10/14/14, revealed exposed electrical wiring above the ceiling tile located in the office next to the Tomography/Computed CT Scan Room.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly in their frames. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview on 10/14/14, revealed a door wedge propping the door open to the Staff Lounge in the Clinic. Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview on 10/14/14, revealed the corridor door to the Dirty B Utility Room did not close and latch properly when tested. Maintenance Staff A verified this observation.

Based on observation and interview, the facility is not providing an all-weather surface from each exit to a public way (an area of safety). This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

1. Observation and interview on 10/14/14, revealed the exit door located by the Administrator's Office has a square cement pad directly outside the door with no sidewalk leading to a public way.
2. Observation and interview on 10/14/14, revealed the exit door located by the Employee Break Room has a square cement pad directly outside the door with no sidewalk leading to a public way.


Maintenance Staff A verified these observations.

Based on observation and interview, the facility is not ensuring that patient room doors and other doors are arranged such that they can opened from inside without the use of a key or special knowledge. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview on 10/14/14, revealed several patient room doors and some office doors were equipped with a deadbolt lock that did not release with a single action turn of the door handle. Maintenance Staff A verified these observations.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift as required. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 patients and a census of 9.

Findings include:

1. Record review and staff interview on 10/14/14, revealed the facility failed to perform fire drills in the 2nd quarter on both first and third shifts and on the third shift on the 4th quarter.
2. Record review and staff interview on 10/14/14, revealed the facility is not varying the fire drill times on each shift. Half of the fire drills documented were between the hours of 1520 and 1600.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide a properly tested and maintained fire alarm system in accordance with National Fire Protection Association (NFPA) 72. The entire facility is directly affected by this deficient practice. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation and interview of the facility's fire alarm inspection documentation on 10/14/14, revealed that the facility is not have the fire alarm system tested/inspected as required by code. The fire alarm system has not been inspected by General Fire and Safety since 6/13/12. Maintenance Staff A verified this observation.

Based on observation, interview and record review, the facility failed to maintain and test smoke detectors for sensitivity in accordance with National Fire Protection Association (NFPA) 72, 7-3.2.1. All smoke detectors throughout the building were affected and all occupants of the building could be affected by this deficient practice. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

Observation, interview and record review on 10/14/14, revealed the facility did not have a sensitivity test performed on their smoke detectors every other year as required. There was no documentation on file to verify when the last sensitivity test had been performed. Maintenance Staff A verified this observation.

Based on record review, interview, and observation, the facility failed to maintain and test a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments and all occupants could be affected by this deficient practice. This facility has 25 licensed beds and at the time of the survey the census was 9.

Findings include:

During record review, interview and observation of the facility's fire safety components on 10/14/14, revealed the absence of documentation to indicate that quarterly inspections of the sprinkler system had been performed. Maintenance Staff A stated that he thought they were being performed by Continental.

Based on observations and interview the facility failed to provide combustible decorations that are flame retardant. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

1. Observation and interview on 10/14/14, revealed the door to Room 210 (office) in the Clinic had the door wrapped in toilet paper.
2. Observation and interview on 10/14/14, revealed a door in the Front Entrance Waiting Area had the door wrapped in toilet paper.

Maintenance Staff A verified these observations.

Based on observation and 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. This facility has 25 certified beds and at the time of the survey the census was 9.

Findings include:

1. Observation and interview on 10/14/14, revealed a missing junction box cover above the lay-in ceiling tile located above the door in the Soiled Linen Room in the Basement.
2. Observation and interview on 10/14/14, revealed two missing blanks in electrical panel LP3 located in the Boiler Room.
3. Observation and interview on 10/14/14, revealed a brown extension cord being used for decorative lights in Room 210 (office) in the Clinic.
Observation and interview on 10/14/14, revealed exposed electrical wiring above the ceiling tile located in the office next to the Tomography/Computed CT Scan Room.

Maintenance Staff A verified these observations.