HospitalInspections.org

Based on observation and interview, the facility is not providing doors to the corridor that stay latched tightly within the door frames. This deficient practice would not prevent the spread of smoke, affecting all occupants in one of three smoke zones of the Cromwell Building. This facility has a capacity of 95 with a census of 49.

Findings include:

1. Observation and interview on 11/08/2012 at 3:12 p.m., revealed the door to Unit C-1 resident room #3 failed to close and latch tightly within the door frame due to faulty latching hardware.

2. Observation and interview on 11/08/2012 at 3:15 p.m., revealed the door to Unit C-1 resident room #8 failed to close and latch tightly within the door frame due to faulty latching hardware.

3. Observation and interview on 11/08/2012 at 3:20 p.m., revealed the door to Unit C-2 resident room #4 failed to close and latch tightly within the door frame due to faulty latching hardware. The Safety Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the three smoke compartments in the Cromwell building. This deficient practice could affect 5 residents, staff and visitors. The facility has a capacity of 95 and a census of 49.

Findings include:

Observation and interview on 11/08/2012 at 3:30 p.m., revealed the facility failed to maintain the School Area Smoke Barrier door. This door failed to close and positively latch while being tested. The Safety Director verified this observation at the time of the survey process.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of three smoke compartments in the Cromwell building. This could affect all staff in the office corridor. The facility has a capacity of 95 and a census of 49.

Findings include:

1. Observations on 11/08/2012 at 3:09 p.m., revealed the facility failed to separate the Office Storage Room near Office #10 from other compartments. This room contained combustible storage, was over one hundred square feet and contained a half inch open center conduit with gray wires penetrating the corridor wall.

2. Observations on 11/08/2012 at 3:10 p.m., revealed the facility failed to separate the Office Storage Room near Office #10 from other compartments. This room contained combustible storage, was over one hundred square feet and contained a two inch open center conduit with gray/yellow wires penetrating the corridor wall. The Safety Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide a properly tested and maintained fire alarm system. The deficient practice could effect the operation of the Fire Alarm System affecting all staff in this room of the Reynolds Building. The facility has a capacity of 95 and a census of 49.

Findings include:

Observation and interview on 11/08/2012 at 12:55 p.m., revealed the facility failed to maintain the fire alarm system in the Ward Nine Corridor. This corridor contained a heat detector that was not securely fastened to the ceiling. The Safety Director verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 5 residents, staff and visitors in this smoke compartment of the Whitte Building. The facility has a capacity of 95 and a census of 49.

Findings include:

1. Observation and interview on 11/08/12 at 1:35 p.m., revealed the facility failed to maintain the Fire Alarm System in the Ward T Day Room. This room contained four smoke detectors with in three feet of an air diffuser.

2. Observation and interview on 11/08/12 at 1:40 p.m., revealed the facility failed to maintain the Fire Alarm System in the Ward T Main Day Room. This room contained a smoke detector with in three feet of an air diffuser. The Safety Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. One of ten fire extinguishers in one of three smoke compartments were affected by the deficient practice. This deficient practice could affect 5 residents, staff and visitors in the Cromwell Building. The facility has a capacity of 95 and a census of 49.

Findings include:

1. Observation of the fire extinguishers on 11/08/2012 at 3:25 p.m., revealed the facility failed to maintain one fire extinguisher in the Kitchen. This extinguisher did not contain any date or initials marked on the extinguisher tag for the month of August 2012.

2. Observation of the fire extinguishers on 11/09/2012 at 09:30 a.m., revealed the facility failed to maintain one fire extinguisher in the Kitchen. This extinguisher did not contain any date or initials marked on the extinguisher tag for the month of August 2012. The Safety Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all residents and staff in the Cromwell Building. The facility has a capacity of 95 and a census of 49.

Findings include:

Observations of the mini blinds in Classroom #2 on 11/08/2012 at 3:45 p.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Safety Director verified this observation at the time of the survey process.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments of the Reynolds building and all of the residents, staff and visitors. The facility has a capacity of 95 and a census of 49.

Findings include:

Staff interview and record review on 11/08/2012 at 11:00 a.m., revealed that the facility failed to provide documentation of weekly visual inspections for the facility's generator. The facility could not provide any documentation for any weekly visual inspections for 2011 and 2012. The Safety Officer verified this through interview and record review at the time of the survey process. The Safety Director stated these tests were completed but failed to be documented.

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, affecting one staff in this corridor of the Whitte Building. The facility had a capacity of 95 and a census of 49.

Findings Include:

1. Observation and interview on 11/08/2012 at 2:18 p.m., revealed the facility failed to maintain the electrical system in the Ward R Corridor. This corridor contained exposed electrical wiring above the lay in tile.

2. Observation and interview on 11/08/2012 at 2:20 p.m., revealed the facility failed to maintain the electrical system in the Ward R Corridor. This corridor contained an open junction box above the lay in tile. The Safety Director verified these observations at the time of the survey process.

Based on observation and interview, the facility is not providing doors to the corridor that stay latched tightly within the door frames. This deficient practice would not prevent the spread of smoke, affecting all occupants in one of three smoke zones of the Cromwell Building. This facility has a capacity of 95 with a census of 49.

Findings include:

1. Observation and interview on 11/08/2012 at 3:12 p.m., revealed the door to Unit C-1 resident room #3 failed to close and latch tightly within the door frame due to faulty latching hardware.

2. Observation and interview on 11/08/2012 at 3:15 p.m., revealed the door to Unit C-1 resident room #8 failed to close and latch tightly within the door frame due to faulty latching hardware.

3. Observation and interview on 11/08/2012 at 3:20 p.m., revealed the door to Unit C-2 resident room #4 failed to close and latch tightly within the door frame due to faulty latching hardware. The Safety Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected one of the three smoke compartments in the Cromwell building. This deficient practice could affect 5 residents, staff and visitors. The facility has a capacity of 95 and a census of 49.

Findings include:

Observation and interview on 11/08/2012 at 3:30 p.m., revealed the facility failed to maintain the School Area Smoke Barrier door. This door failed to close and positively latch while being tested. The Safety Director verified this observation at the time of the survey process.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects one of three smoke compartments in the Cromwell building. This could affect all staff in the office corridor. The facility has a capacity of 95 and a census of 49.

Findings include:

1. Observations on 11/08/2012 at 3:09 p.m., revealed the facility failed to separate the Office Storage Room near Office #10 from other compartments. This room contained combustible storage, was over one hundred square feet and contained a half inch open center conduit with gray wires penetrating the corridor wall.

2. Observations on 11/08/2012 at 3:10 p.m., revealed the facility failed to separate the Office Storage Room near Office #10 from other compartments. This room contained combustible storage, was over one hundred square feet and contained a two inch open center conduit with gray/yellow wires penetrating the corridor wall. The Safety Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to provide a properly tested and maintained fire alarm system. The deficient practice could effect the operation of the Fire Alarm System affecting all staff in this room of the Reynolds Building. The facility has a capacity of 95 and a census of 49.

Findings include:

Observation and interview on 11/08/2012 at 12:55 p.m., revealed the facility failed to maintain the fire alarm system in the Ward Nine Corridor. This corridor contained a heat detector that was not securely fastened to the ceiling. The Safety Director verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect 5 residents, staff and visitors in this smoke compartment of the Whitte Building. The facility has a capacity of 95 and a census of 49.

Findings include:

1. Observation and interview on 11/08/12 at 1:35 p.m., revealed the facility failed to maintain the Fire Alarm System in the Ward T Day Room. This room contained four smoke detectors with in three feet of an air diffuser.

2. Observation and interview on 11/08/12 at 1:40 p.m., revealed the facility failed to maintain the Fire Alarm System in the Ward T Main Day Room. This room contained a smoke detector with in three feet of an air diffuser. The Safety Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. One of ten fire extinguishers in one of three smoke compartments were affected by the deficient practice. This deficient practice could affect 5 residents, staff and visitors in the Cromwell Building. The facility has a capacity of 95 and a census of 49.

Findings include:

1. Observation of the fire extinguishers on 11/08/2012 at 3:25 p.m., revealed the facility failed to maintain one fire extinguisher in the Kitchen. This extinguisher did not contain any date or initials marked on the extinguisher tag for the month of August 2012.

2. Observation of the fire extinguishers on 11/09/2012 at 09:30 a.m., revealed the facility failed to maintain one fire extinguisher in the Kitchen. This extinguisher did not contain any date or initials marked on the extinguisher tag for the month of August 2012. The Safety Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide draperies, curtains and window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility could not provide documentation that the window blinds were flame resistant. This has the potential of affecting all residents and staff in the Cromwell Building. The facility has a capacity of 95 and a census of 49.

Findings include:

Observations of the mini blinds in Classroom #2 on 11/08/2012 at 3:45 p.m., revealed they were not metal and were not tagged as being flame retardant. The facility could not provide documentation that the vinyl mini blinds were flame retardant. The Safety Director verified this observation at the time of the survey process.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect all smoke compartments of the Reynolds building and all of the residents, staff and visitors. The facility has a capacity of 95 and a census of 49.

Findings include:

Staff interview and record review on 11/08/2012 at 11:00 a.m., revealed that the facility failed to provide documentation of weekly visual inspections for the facility's generator. The facility could not provide any documentation for any weekly visual inspections for 2011 and 2012. The Safety Officer verified this through interview and record review at the time of the survey process. The Safety Director stated these tests were completed but failed to be documented.

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, affecting one staff in this corridor of the Whitte Building. The facility had a capacity of 95 and a census of 49.

Findings Include:

1. Observation and interview on 11/08/2012 at 2:18 p.m., revealed the facility failed to maintain the electrical system in the Ward R Corridor. This corridor contained exposed electrical wiring above the lay in tile.

2. Observation and interview on 11/08/2012 at 2:20 p.m., revealed the facility failed to maintain the electrical system in the Ward R Corridor. This corridor contained an open junction box above the lay in tile. The Safety Director verified these observations at the time of the survey process.