HospitalInspections.org

Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating between the nursing home and the hospital portion of the facility. The wall is penetrated above the lay-in ceiling tile. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 25 and a census of 5 patients.

Findings include:

1. Observation and staff interview on 1/26/16 at 10:58 a.m., the two-hour firewall located between the hospital (Rehab Ctr) and the nursing facility (Whispering Heights) had an open ended one inch metal conduit that was not sealed.
2. Observation and staff interview on 1/26/16 at 11:17 a.m., the two-hour firewall located between the hospital and the tunnel had 1/2 inch penetration surrounding metal flex above the ceiling tile.
According to Maintenance Staff, these are two-hour firewalls intended to separate the occupancies.

Based on observation and staff interview, the facility is not providing doors with single action locking mechanisms. This deficient practice would not prevent the spread of smoke. This facility has a capacity of 25 with a census of 5 patients.

Findings include:

Observation and staff interview on 1/26/16 at 11:40 a.m. revealed the following doors were equipped with deadbolt action locking mechanism:
- Rehab Center locker rooms
- X-ray room
-CT scan room
Maintenance Staff confirmed these observations during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected all of the basement level. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Observation and staff interview of the laundry/storage room on 1/26/16 at 11:53 a.m. revealed two 1/2 inch penetrations surrounded two sprinkler pipes on the east wall. Maintenance Staff confirmed this observation during the survey process.

Based on observation and record review, the facility did not provide a directional exit sign for the pool exit door in the Rehab Center. This deficient practice effects staff and visitors in this facility with a capacity of 25.

Findings include:

Observation and staff interview on 1/26/16, revealed no directional exit sign for the pool exit door located in the Rehab Center. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. Maintenance Staff verified this observation during the survey process.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 5 patients.

Findings include:

Review of the facility ' s fire drill records and staff interview on 1/26/16 at 12:28 p.m., revealed the third quarter was missing the third shift fire drills in 2015. Maintenance Staff verified this observation during the survey process.

Based on observation and staff interview, this facility is not providing a firewall with a two-hour fire rating between the nursing home and the hospital portion of the facility. The wall is penetrated above the lay-in ceiling tile. This deficient practice affects all occupants including staff, visitors and residents. This facility has a capacity of 25 and a census of 5 patients.

Findings include:

1. Observation and staff interview on 1/26/16 at 10:58 a.m., the two-hour firewall located between the hospital (Rehab Ctr) and the nursing facility (Whispering Heights) had an open ended one inch metal conduit that was not sealed.
2. Observation and staff interview on 1/26/16 at 11:17 a.m., the two-hour firewall located between the hospital and the tunnel had 1/2 inch penetration surrounding metal flex above the ceiling tile.
According to Maintenance Staff, these are two-hour firewalls intended to separate the occupancies.

Based on observation and staff interview, the facility is not providing doors with single action locking mechanisms. This deficient practice would not prevent the spread of smoke. This facility has a capacity of 25 with a census of 5 patients.

Findings include:

Observation and staff interview on 1/26/16 at 11:40 a.m. revealed the following doors were equipped with deadbolt action locking mechanism:
- Rehab Center locker rooms
- X-ray room
-CT scan room
Maintenance Staff confirmed these observations during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected all of the basement level. This facility has a capacity of 25 and a census of 5 residents.

Findings include:

Observation and staff interview of the laundry/storage room on 1/26/16 at 11:53 a.m. revealed two 1/2 inch penetrations surrounded two sprinkler pipes on the east wall. Maintenance Staff confirmed this observation during the survey process.

Based on observation and record review, the facility did not provide a directional exit sign for the pool exit door in the Rehab Center. This deficient practice effects staff and visitors in this facility with a capacity of 25.

Findings include:

Observation and staff interview on 1/26/16, revealed no directional exit sign for the pool exit door located in the Rehab Center. According to the facility layout, which is used in conjunction with the emergency procedures, this designated exit is a required exit. Maintenance Staff verified this observation during the survey process.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 5 patients.

Findings include:

Review of the facility ' s fire drill records and staff interview on 1/26/16 at 12:28 p.m., revealed the third quarter was missing the third shift fire drills in 2015. Maintenance Staff verified this observation during the survey process.