HospitalInspections.org

Based on observation and staff interview, the facility fails to assure that barrier walls are maintained and are free of penetrations. The deficient practice compromises the fire resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 03/22/2012, at 3:00 p.m., it is observed that the fire barrier wall separating the Hospital and Clinic has unsealed penetrations around piping and conduit that pass through it.

Maintenance Staff A and B were present and acknowledged the unsealed penetrations in the rated wall.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 03/22/2012, it is observed:

-- 1. At 2:42 p.m., smoke barrier wall in north/south corridor near the Kitchen has unsealed gaps around wires and conduit.

-- 2. At 2:47 p.m., smoke barrier wall in east/west corridor near the Kitchen has unsealed gaps around piping and conduit.

Maintenance Staff A and B were present and acknowledged the unsealed gaps in smoke barrier walls.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

Findings Include:

During the tour conducted on 03/22/2012, at 3:30 p.m., it is observed that the door to the Bio-Hazard Storage Room is held open with a non-approved wooden wedge.

Maintenance Staff A and B were present and acknowledged that the door was held open with a wooden wedged. Maintenance Staff B immediately removed the wedge.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based upon observation and staff interview, the facility fails to assure that emergency lighting of at least 1? hour duration is provided in accordance with 7.9. The deficient practice could result in a failure to illuminate exit pathways in the event of an emergency or loss of power, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of this survey.

Findings include:

During the tour conducted on 03/22/2012, at 3:20 p.m., it is observed that the battery back-up emergency lighting unit provided in the Pharmacy is unplugged and not charging.

Maintenance Staff A and B were present and acknowledged that the emergency lighting unit was not plugged in and would not function in the event of a loss of power.

NFPA Standard: Emergency illumination shall be provided for not less than 1? hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

Based on observation and record review, the facility does not assure that cooking facilities are protected in accordance with NFPA 96. The deficient practice could result in the perpetuation of a kitchen range fire without proper protection, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 03/22/2012, a review of records between 12:45 p.m. and 1:30 p.m. revealed that the kitchen ventilation and duct work is past due for cleaning. The last documented cleaning was performed on 02/09/2010. The cleaning company has recommended that the hood and duct work be cleaned on an annual basis.

Maintenance Staff A and B were present and acknowledged the results of the records review.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 03/22/2012, at 2:25 p.m., it is observed that an extension cord, encased in conduit, passes through an outside wall in the sprinkler riser room. The cord is wired into and provides power to a timer for the lawn sprinkler system.

Maintenance Staff A and B were present and acknowledged the inappropriate use of an extension cord.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and staff interview, the facility fails to assure that barrier walls are maintained and are free of penetrations. The deficient practice compromises the fire resistance rating of the wall and would not prevent the passage of fire or smoke to other areas of the building, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 03/22/2012, at 3:00 p.m., it is observed that the fire barrier wall separating the Hospital and Clinic has unsealed penetrations around piping and conduit that pass through it.

Maintenance Staff A and B were present and acknowledged the unsealed penetrations in the rated wall.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 03/22/2012, it is observed:

-- 1. At 2:42 p.m., smoke barrier wall in north/south corridor near the Kitchen has unsealed gaps around wires and conduit.

-- 2. At 2:47 p.m., smoke barrier wall in east/west corridor near the Kitchen has unsealed gaps around piping and conduit.

Maintenance Staff A and B were present and acknowledged the unsealed gaps in smoke barrier walls.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview, the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

Findings Include:

During the tour conducted on 03/22/2012, at 3:30 p.m., it is observed that the door to the Bio-Hazard Storage Room is held open with a non-approved wooden wedge.

Maintenance Staff A and B were present and acknowledged that the door was held open with a wooden wedged. Maintenance Staff B immediately removed the wedge.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based upon observation and staff interview, the facility fails to assure that emergency lighting of at least 1? hour duration is provided in accordance with 7.9. The deficient practice could result in a failure to illuminate exit pathways in the event of an emergency or loss of power, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of this survey.

Findings include:

During the tour conducted on 03/22/2012, at 3:20 p.m., it is observed that the battery back-up emergency lighting unit provided in the Pharmacy is unplugged and not charging.

Maintenance Staff A and B were present and acknowledged that the emergency lighting unit was not plugged in and would not function in the event of a loss of power.

NFPA Standard: Emergency illumination shall be provided for not less than 1? hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

Based on observation and record review, the facility does not assure that cooking facilities are protected in accordance with NFPA 96. The deficient practice could result in the perpetuation of a kitchen range fire without proper protection, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 03/22/2012, a review of records between 12:45 p.m. and 1:30 p.m. revealed that the kitchen ventilation and duct work is past due for cleaning. The last documented cleaning was performed on 02/09/2010. The cleaning company has recommended that the hood and duct work be cleaned on an annual basis.

Maintenance Staff A and B were present and acknowledged the results of the records review.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting 1 of 7 smoke zones. The facility has a capacity of 25 with a census of 1 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 03/22/2012, at 2:25 p.m., it is observed that an extension cord, encased in conduit, passes through an outside wall in the sprinkler riser room. The cord is wired into and provides power to a timer for the lawn sprinkler system.

Maintenance Staff A and B were present and acknowledged the inappropriate use of an extension cord.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8