HospitalInspections.org

Based on observations and interviews, the facility failed to provide building construction that is in accordance with 19.1.6.2,19.1.6.3, 19.1.6.4,19.3.5.1. This affects 2 of 13 smoke zones and all residents in the facility. The facility had a capacity of 25 and a census of 14.

Findings include:

1. Observations and staff interviews on 10/01/13, revealed a gap (approximately 1/4 inch) around a penetration located above the smoke separation doors located by Room 1037.
2. Observations and staff interviews on 10/01/13, revealed a gap (approximately 1/2 inch) around the a pipe located above the smoke separation doors located by Room 1200.

Maintenance Staff A verified these observations.

Based on observations and interviews, the facility failed to provide hazardous areas in accordance with 8.4.1, 19.3.5.4, 19.3.2.1. This affects 1 of 13 smoke zones and all of the staff members using these areas. The facility has a capacity of 25 and a census of 14.

Findings include:

Observations and staff interviews on 10/01/13, revealed the storage room located in the Home Health and Hospice area was not equipped with door closing hardware. This room was being used as a storage room and was greater that 50 square feet and opened to the corridor.

Based on observation and interview, the facility failed to provide emergency lighting in accordance with 7.9, 18.2.9.1, 19.2.9.1. This affects the entire facility. The facility has a capacity of 25 and a census of 14.

Findings include:

Observations and staff interviews on 10/01/13, revealed the emergency lighting located in the Generator Room did not function properly when tested during this survey.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide exit lighting in accordance with 7.10, 18.2.10.1, 19.2.10.1. This affects the entire facility. The facility has a capacity of 25 and a census of 14.

Findings include:

Observations and staff interviews on 10/01/13, revealed the exit lighting located in corridor by the Door to Stairway 6 did not function properly when tested during this survey.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to conduct fire drills in accordance with 18.7.1.2, 19.7.1.2. This affects the entire facility and all residents and staff. The facility has a capacity of 25 and a census of 14.

Findings include:

Record reviews and staff interviews on 10/01/13, revealed the facility failed to conduct a fire drill on the evening shift during the 2nd quarter of this year and for the night shift during the last quarter of the 4th quarter of last year. Second shift quarterly inspections were conducted at 15:36 and two at 15:38.

Maintenance Staff A verified this observation.

Based on observations and interviews, this facility failed to provide a fire alarm system in accordance with 19.3.4, 9.6 and National Fire Protection Association 72. This affects the entire facility and the residents and staff. The facility has a capacity of 25 and a census of 14.

Findings include:

1) Observations and staff interviews on 10/01/13, revealed the electrical breaker that was used to supply power to the Fire Alarm was not secured with a mechanical lockout device.
2)Observations and staff interviews on 10/01/13, revealed the horn located by the door the OB Ward failed to sound when tested during this survey.
3) Observations and staff interviews on 10/01/13, revealed the strobe light located by Room 1000 was out of sequence with the other strobes.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide a complete sprinkler system in accordance with National Fire Protection Association 13, 1999 edition, National Fire Protection Association 25,1999 edition, 18.7.6, 19.7.6, 4.6.12. This affects the entire facility its residence and staff residents. The facility had a capacity of 25 and a census of 14.

Findings include:

1) Observations and staff interviews on 10/01/13, revealed a sprinkler head located in the Elevator Room that was obstructed by a HVAC Unit.
2) Observations and staff interviews on 10/001/13, revealed an obstructed sprinkler head located in Room 1721 Electrical Room.
3) Observations and staff interviews on 10/001/13, revealed an obstructed sprinkler head located left of the the door to Room 1200.

Maintenance Staff A verified these observations.

Based on observations and interview, the facility failed to maintain their electrical system in accordance with National Fire Protection Association 70, National Electrical Code 9.1.2. This affects the entire facility its residence and staff. The facility has a capacity of 25 and a census of 14.

Findings include:

1. Observations and staff interview on 10/01/13, revealed a plastic surge protector located in the Respiratory Therapy Room.
2. Observations and staff interviews on 10/001/13, revealed a missing junction box cover located above the corridor barrier doors by Room 1595.

Maintenance Staff A verified these observations.

Based on observations and interviews, the facility failed to provide building construction that is in accordance with 19.1.6.2,19.1.6.3, 19.1.6.4,19.3.5.1. This affects 2 of 13 smoke zones and all residents in the facility. The facility had a capacity of 25 and a census of 14.

Findings include:

1. Observations and staff interviews on 10/01/13, revealed a gap (approximately 1/4 inch) around a penetration located above the smoke separation doors located by Room 1037.
2. Observations and staff interviews on 10/01/13, revealed a gap (approximately 1/2 inch) around the a pipe located above the smoke separation doors located by Room 1200.

Maintenance Staff A verified these observations.

Based on observations and interviews, the facility failed to provide hazardous areas in accordance with 8.4.1, 19.3.5.4, 19.3.2.1. This affects 1 of 13 smoke zones and all of the staff members using these areas. The facility has a capacity of 25 and a census of 14.

Findings include:

Observations and staff interviews on 10/01/13, revealed the storage room located in the Home Health and Hospice area was not equipped with door closing hardware. This room was being used as a storage room and was greater that 50 square feet and opened to the corridor.

Based on observation and interview, the facility failed to provide emergency lighting in accordance with 7.9, 18.2.9.1, 19.2.9.1. This affects the entire facility. The facility has a capacity of 25 and a census of 14.

Findings include:

Observations and staff interviews on 10/01/13, revealed the emergency lighting located in the Generator Room did not function properly when tested during this survey.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide exit lighting in accordance with 7.10, 18.2.10.1, 19.2.10.1. This affects the entire facility. The facility has a capacity of 25 and a census of 14.

Findings include:

Observations and staff interviews on 10/01/13, revealed the exit lighting located in corridor by the Door to Stairway 6 did not function properly when tested during this survey.

Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to conduct fire drills in accordance with 18.7.1.2, 19.7.1.2. This affects the entire facility and all residents and staff. The facility has a capacity of 25 and a census of 14.

Findings include:

Record reviews and staff interviews on 10/01/13, revealed the facility failed to conduct a fire drill on the evening shift during the 2nd quarter of this year and for the night shift during the last quarter of the 4th quarter of last year. Second shift quarterly inspections were conducted at 15:36 and two at 15:38.

Maintenance Staff A verified this observation.

Based on observations and interviews, this facility failed to provide a fire alarm system in accordance with 19.3.4, 9.6 and National Fire Protection Association 72. This affects the entire facility and the residents and staff. The facility has a capacity of 25 and a census of 14.

Findings include:

1) Observations and staff interviews on 10/01/13, revealed the electrical breaker that was used to supply power to the Fire Alarm was not secured with a mechanical lockout device.
2)Observations and staff interviews on 10/01/13, revealed the horn located by the door the OB Ward failed to sound when tested during this survey.
3) Observations and staff interviews on 10/01/13, revealed the strobe light located by Room 1000 was out of sequence with the other strobes.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide a complete sprinkler system in accordance with National Fire Protection Association 13, 1999 edition, National Fire Protection Association 25,1999 edition, 18.7.6, 19.7.6, 4.6.12. This affects the entire facility its residence and staff residents. The facility had a capacity of 25 and a census of 14.

Findings include:

1) Observations and staff interviews on 10/01/13, revealed a sprinkler head located in the Elevator Room that was obstructed by a HVAC Unit.
2) Observations and staff interviews on 10/001/13, revealed an obstructed sprinkler head located in Room 1721 Electrical Room.
3) Observations and staff interviews on 10/001/13, revealed an obstructed sprinkler head located left of the the door to Room 1200.

Maintenance Staff A verified these observations.

Based on observations and interview, the facility failed to maintain their electrical system in accordance with National Fire Protection Association 70, National Electrical Code 9.1.2. This affects the entire facility its residence and staff. The facility has a capacity of 25 and a census of 14.

Findings include:

1. Observations and staff interview on 10/01/13, revealed a plastic surge protector located in the Respiratory Therapy Room.
2. Observations and staff interviews on 10/001/13, revealed a missing junction box cover located above the corridor barrier doors by Room 1595.

Maintenance Staff A verified these observations.