HospitalInspections.org

Based on observations, the facility failed to maintain 5 of 20 Smoke Barriers free of penetrations. This affects approximately 3 patients and 20 staff within the affected zones. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10 revealed the following:

1. There was a center of conduit penetration (approximately 1 and 1/4 inch in size), located above the suspended ceiling, in the Smoke Barrier located near Room G-27.

2. There was a gap (approximately 1/4 inch in size), located above the suspended ceiling, where the barrier meets the roof, in the Dietary Entrance Smoke Barrier.

3. There was a conduit penetration (approximately 1/4 inch in size), located above the suspended ceiling, in the 1981/2000 Edition smoke barrier.

4. There was a hole (approximately 2 inches by 2 inches in size), located above the suspended ceiling, in the 1981/2000 Edition smoke barrier.

5. There was a center of conduit penetration (approximately 4 inches in size), located above the suspended ceiling, in the Emergency Room barrier located near Room S-08.

6. There was a wire penetration (approximately 1/8 inch in size), located above the suspended ceiling, in the Medical Surgery/Infusion Therapy barrier.

Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observations, the facility failed to maintain 4 of 20 smoke barrier doors to close and latch properly. This affects approximately 9 patients and 25 staff within the affected zones. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10, revealed the following smoke barrier doors failed to close and latch properly when tested.

1. The barrier doors located at the Dietary entrance
2. The barrier doors located near the Radiologists Office.
3. The barrier doors located at the Radiology Department entrance.
4. The barrier doors located between the Medical Surgery Department and the O.B Department.

Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observations, the facility failed to maintain 4 hazardous rooms properly separated. This affects 3 of 33 smoke zones, affecting approximately 22 staff members in the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10, revealed the following:

1. The door to the Mechanical Room in the 1995 Edition failed to close and latch properly into the door frame when tested.

2. Server Room #G24 in the Basement revealed a conduit penetration (approximately 1/2 inch in size) and a center of conduit penetration (approximately 2 inches in size) located above the door.

3. The door to Room #A151 (Cardboard Storage, approximately 200 square feet) failed to be equipped with an Underwriters Laboratory (U.L.) listed self-closing device.

4. The Electrical Room in the 1990 Edition revealed 2 conduit penetrations (approximately 1/2 inches in size) located on the north wall.

Maintenance Staff A and Facility Director A confirmed these findings.

Based on observations, the facility failed to provide an approved exit discharge from 3 exits. This affects 2 of 33 zones, affecting approximately 7 patients and 10 staff members within the facility. The facility had a license of 25 residents and a capacity of 9 residents.

Findings include:

Observations on 3-16-10, revealed the following:

1. Two exit doors located in the Kitchen were equipped with a Dead Bolt style latching device that required a pinching action to release the latch.

2. The absence of a paved sidewalk to the public way at the exit discharge from the East Center Stairwell exit. This exit is marked as such with an approved exit light located directly above the door, but was only maintained with a concrete pad measuring approximately 3 feet by 3 feet.


Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observations and record review, the facility failed to properly perform and document the required 30 second monthly tests and the required 90 minute annual test of the facilities emergency light units. This affects all occupants within the facility. The facility had a license of 25 patients and a census of 9 patients.

Findings include:

Observations and record review on 3-16-10, revealed the absence of a monthly 30 second test of the facilities emergency light units during the month of February, 2010 (last documentation was on 1-31-10). The facility also failed to perform and document a 90 minute test of the buildings emergency lights during the past 12 months (last documentation was on 2-10-09).

Maintenance Staff A and Facilities Director confirmed these findings.

Based on observations, the facility failed to assure exit signs were properly displayed and visible within the facility at 1 location. This affects 1 of 33 smoke zones, affecting approximately 7 patients and 6 staff members within the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10, revealed the facility failed to provide a visible illuminated exit sign located at the "T" intersection of the Medical Surgery Nurses Station to indicate the path of egress.

Maintenance Staff A and Facilities Director A confirmed this finding.

Based on record review, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition. This affects all smoke zones, affecting all occupants within the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Record review on 3-16-10, revealed the facility failed to properly perform and document the required semi-annual test of the buildings fire alarm system. The facility only documented one fire alarm inspection for the calendar year of 2009 (Dec.1st).

Maintenance Staff A and Facilities Director A confirmed this finding.

Based on observations and record review, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition. This affects all smoke zones, affecting all occupants throughout the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations and record review on 3-16-10 revealed the following.

1) A fusible link sprinkler head located in north corridor of the Large Storage Room in the basement revealed a paint like substance on it.

2) The facility failed to properly perform and document the required quarterly inspections of the buildings automatic sprinkler system. They failed to document an inspection during the last quarter of 2009. The last documented inspection was on 8-1-09.

Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observation, the facility failed to properly maintain the storage of compressed medical gases in accordance with Section 4.3.1.1.2, NFPA 99, Health Care Facilities, 1999 edition. This affects 2 of 33 smoke zones, affecting approximately 2 patients and 8 staff members within the affected zones. The facility had a license of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10, revealed 1 oxygen bottle that were not properly secured in the Oxygen Storage room of the Emergency Room and 1 oxygen bottle that was not properly secured in the 2000 Edition Mechanical Room.

Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observations, 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 affects 3 of 33 smoke zones, affecting approximately 7 patients and 20 staff members within the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 3-16-10, revealed the following:

1. A coffee pot, microwave and a refrigerator was plugged into a surge protector located in the Central Supply Room.

2. A refrigerator was plugged into a surge protector located in the Ambulance Office.

3. Exposed wires were present in the Basement Laundry Room, near the east dryer.

4. Electrical Panel #EB1 located in the Ambulatory Surgical storeroom was blocked by storage items, denying immediate unobstructed access.

Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observations, the facility failed to maintain 5 of 20 Smoke Barriers free of penetrations. This affects approximately 3 patients and 20 staff within the affected zones. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10 revealed the following:

1. There was a center of conduit penetration (approximately 1 and 1/4 inch in size), located above the suspended ceiling, in the Smoke Barrier located near Room G-27.

2. There was a gap (approximately 1/4 inch in size), located above the suspended ceiling, where the barrier meets the roof, in the Dietary Entrance Smoke Barrier.

3. There was a conduit penetration (approximately 1/4 inch in size), located above the suspended ceiling, in the 1981/2000 Edition smoke barrier.

4. There was a hole (approximately 2 inches by 2 inches in size), located above the suspended ceiling, in the 1981/2000 Edition smoke barrier.

5. There was a center of conduit penetration (approximately 4 inches in size), located above the suspended ceiling, in the Emergency Room barrier located near Room S-08.

6. There was a wire penetration (approximately 1/8 inch in size), located above the suspended ceiling, in the Medical Surgery/Infusion Therapy barrier.

Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observations, the facility failed to maintain 4 of 20 smoke barrier doors to close and latch properly. This affects approximately 9 patients and 25 staff within the affected zones. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10, revealed the following smoke barrier doors failed to close and latch properly when tested.

1. The barrier doors located at the Dietary entrance
2. The barrier doors located near the Radiologists Office.
3. The barrier doors located at the Radiology Department entrance.
4. The barrier doors located between the Medical Surgery Department and the O.B Department.

Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observations, the facility failed to maintain 4 hazardous rooms properly separated. This affects 3 of 33 smoke zones, affecting approximately 22 staff members in the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10, revealed the following:

1. The door to the Mechanical Room in the 1995 Edition failed to close and latch properly into the door frame when tested.

2. Server Room #G24 in the Basement revealed a conduit penetration (approximately 1/2 inch in size) and a center of conduit penetration (approximately 2 inches in size) located above the door.

3. The door to Room #A151 (Cardboard Storage, approximately 200 square feet) failed to be equipped with an Underwriters Laboratory (U.L.) listed self-closing device.

4. The Electrical Room in the 1990 Edition revealed 2 conduit penetrations (approximately 1/2 inches in size) located on the north wall.

Maintenance Staff A and Facility Director A confirmed these findings.

Based on observations, the facility failed to provide an approved exit discharge from 3 exits. This affects 2 of 33 zones, affecting approximately 7 patients and 10 staff members within the facility. The facility had a license of 25 residents and a capacity of 9 residents.

Findings include:

Observations on 3-16-10, revealed the following:

1. Two exit doors located in the Kitchen were equipped with a Dead Bolt style latching device that required a pinching action to release the latch.

2. The absence of a paved sidewalk to the public way at the exit discharge from the East Center Stairwell exit. This exit is marked as such with an approved exit light located directly above the door, but was only maintained with a concrete pad measuring approximately 3 feet by 3 feet.


Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observations and record review, the facility failed to properly perform and document the required 30 second monthly tests and the required 90 minute annual test of the facilities emergency light units. This affects all occupants within the facility. The facility had a license of 25 patients and a census of 9 patients.

Findings include:

Observations and record review on 3-16-10, revealed the absence of a monthly 30 second test of the facilities emergency light units during the month of February, 2010 (last documentation was on 1-31-10). The facility also failed to perform and document a 90 minute test of the buildings emergency lights during the past 12 months (last documentation was on 2-10-09).

Maintenance Staff A and Facilities Director confirmed these findings.

Based on observations, the facility failed to assure exit signs were properly displayed and visible within the facility at 1 location. This affects 1 of 33 smoke zones, affecting approximately 7 patients and 6 staff members within the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10, revealed the facility failed to provide a visible illuminated exit sign located at the "T" intersection of the Medical Surgery Nurses Station to indicate the path of egress.

Maintenance Staff A and Facilities Director A confirmed this finding.

Based on record review, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition. This affects all smoke zones, affecting all occupants within the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Record review on 3-16-10, revealed the facility failed to properly perform and document the required semi-annual test of the buildings fire alarm system. The facility only documented one fire alarm inspection for the calendar year of 2009 (Dec.1st).

Maintenance Staff A and Facilities Director A confirmed this finding.

Based on observations and record review, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition. This affects all smoke zones, affecting all occupants throughout the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations and record review on 3-16-10 revealed the following.

1) A fusible link sprinkler head located in north corridor of the Large Storage Room in the basement revealed a paint like substance on it.

2) The facility failed to properly perform and document the required quarterly inspections of the buildings automatic sprinkler system. They failed to document an inspection during the last quarter of 2009. The last documented inspection was on 8-1-09.

Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observation, the facility failed to properly maintain the storage of compressed medical gases in accordance with Section 4.3.1.1.2, NFPA 99, Health Care Facilities, 1999 edition. This affects 2 of 33 smoke zones, affecting approximately 2 patients and 8 staff members within the affected zones. The facility had a license of 25 patients and a census of 9 patients.

Findings include:

Observations on 3-16-10, revealed 1 oxygen bottle that were not properly secured in the Oxygen Storage room of the Emergency Room and 1 oxygen bottle that was not properly secured in the 2000 Edition Mechanical Room.

Maintenance Staff A and Facilities Director A confirmed these findings.

Based on observations, 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 affects 3 of 33 smoke zones, affecting approximately 7 patients and 20 staff members within the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 3-16-10, revealed the following:

1. A coffee pot, microwave and a refrigerator was plugged into a surge protector located in the Central Supply Room.

2. A refrigerator was plugged into a surge protector located in the Ambulance Office.

3. Exposed wires were present in the Basement Laundry Room, near the east dryer.

4. Electrical Panel #EB1 located in the Ambulatory Surgical storeroom was blocked by storage items, denying immediate unobstructed access.

Maintenance Staff A and Facilities Director A confirmed these findings.