HospitalInspections.org

Based on observation, it was determined the facility is a one-story building and consisted of a non-combustible type II (222) protected building. The facility failed to assure minimum building construction requirements were maintained. This facility has a capacity of 25 patients and at the time of the survey the census was 11.

Findings include:

1. Observations on 12/14/10, revealed numerous holes in the ceiling of the Clinic Basement.
2. Observations on 12/14/10, revealed gaps around penetrations above the Medical Vac Pump Station.
3. Observations on 12/14/10, revealed holes in the Storage Area in the Clinic.

Maintenance Staff A verified these observations.

Based on surveyor observation, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. This facility has a capacity of 25 and a census of 11 .

Findings include:

1. Observations on 12/14/10, revealed the corridor door to the Dumb Waiter Closet on the lower level did not close and latch properly when tested.
2. Observations on 12/1/4/10, revealed the OB Utility Hall corridor door did not close and latch properly when tested.
3. Observations on 12/14/10, revealed the corridor door the the Hospice Room was propped open with a wedge.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain smoke doors to close and resist the passage of smoke. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

Observations on 12/14/10, revealed the smoke doors located next to the physician's lounge would not close and latch properly when tested. Maintenance Staff A verified this observation.

Based on observations, the facility failed to provide separation of hazardous areas from other compartments. The facility has a capacity of 25 and at the time of the survey the census was 11 patients.

Findings include:

1. Observations on 12/14/10, revealed multiple pipe penetrations with gaps (ranging from 1/8 inch to 1/2 inch in size) on the corridor wall of the Oxygen Storage Room on the lower level.
2. Observations on 12/14/10, revealed the absence of a self-closing device on the corridor door to the Oxygen Storage Room on the lower level.
3. Observations on 12/14/10, revealed a hole (approximately 3 inches in size), multiple pipe penetration with gaps around them (ranging in size from 1/4 inch to 1 inch), and some gaps around penetrations filled with foam insulation instead of fire caulk in the South End Hall Storage Room by the elevator equipment room on the lower level.
4. Observations on 12/14/10, revealed no self-closure on the corridor door to Purchasing.
5. Observations on 12/14/10, revealed gaps above the north doors of Purchasing.
6. Observations on 12/14/10, revealed the corridor door to the Laundry Room in the Clinic did not close and latch properly when tested. This door was also propped open with a scale.

Maintenance Staff A verified these observations.

(A)
Based on observation, the facility is not providing unobstructed corridors that provides a clear path of egress in the lower level. This facility is not providing a clear and unobstructed corridor. This facility has a census of 11 and a capacity of 25 patients.

Findings include:

Observations on 12/14/10, revealed numerous items being stored in the South Lower Level Corridor which leads to the outdoors. Maintenance Staff A verified this observation.

(B)
Based on observations, the facility failed to maintain exits readily accessible at all times in accordance with 7.1. This deficient practice could affect occupants utilizing the Lower Level. This facility has a capacity of 25 patients and a census of 11.

Findings include:

1. Observations on 12/14/10, revealed a dealbolt lock for the South Exterior Exit Hallway on the Lower Level. Opening this door requires a person to unlock the deadbolt before turning the handle to exit, thus requiring a double action instead of the required single action.
2. Observations on 12/14/10, revealed the absence of panic hardware on the South Double Doors located by the elevator equipment room. These doors lead into the exit access which then goes outdoors. According the the facilities layout, this is a marked and required exit.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility in darkness. Three exits were equipped with a light fixture just outside the door that only had one light bulb. This facility has a capacity of 25 and a census of 11.

Findings include:

Observations on 12/14/10, revealed the following exits were equipped with a single source of light (bulb): South Lower Level exit stairs, North Stairwell Exit on the main level, and North Center Exit by the chillers on the main level. Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain two emergency lights located in the Clinic. This deficient practice could affect all occupants in the Clinic.

Findings include:

Observations on 12/14/10, revealed the emergency lights located in the following areas of the Clinic did not operate properly when tested: near Dr. K's Office and at the West Exterior Door. Maintenance Staff A verified these observations.

Based on observations, the facility failed to maintain the some exit signs located in the Clinic. This deficient practice could affect all occupants of the Clinic.

Findings include:

Observations on 12/14/10, revealed the exit signs in the following areas of the Clinic were not properly illuminated: near Dr. K's Office, at the west exterior exit door, and near Exam Room 8A. Maintenance Staff A verified these observations.

Based upon record review, the facility is not conducting fire drills at varied times on each shift. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 25 patients and a census of 11.

Findings include:

Review of the facilities fire drill records on 12/14/10, revealed that fire drills on the second shift had all been conducted between the hours of 1545 and 1610, and all the fire drills on the third shift between the hours of 0652 and 0658. The facility was also missing a drill for the fourth quarter on third shift. Maintenance Staff A verified these observations.

Based on observation, the facility failed to properly protect and label the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

Observations on 12/14/10, revealed the circuit breaker for the fire alarms primary power supply was located in electrical panel NLSA (breaker #20) . The circuit breaker was not mechanically protected and was not properly labeled. Maintenance Staff A verified this observation.

Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed with direct airflow, nor closer than three feet to air supply or air return. Installation of smoke detectors close to a ceiling fan/air supply/air return can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 7 .

Findings include:

1. Observations on 12/14/10, revealed the following areas had smoke detectors located within three feet of an air supply, air return or ceiling fan: Community Relation/Endowment Office, Human Resource Assistant/Auxiliary Office, Feeding Clinic, PT Hallway, Mammography Room, Ultrasound Room, Conference Room 2 (2 detectors), Purchasing by Karen's Desk, Lynette's Office, and Respiratory Therapy (near entrance door). Maintenance Staff A verified these observations.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, 1998 edition. This facility has a capacity of 25 patients and a census of patients.

Findings include:

1. Observations on 12/14/10 , revealed mixed quick response and standard response sprinkler heads in the reception/waiting area of Community Home Health.
2. Observations on 12/14/10, revealed a missing escutcheon ring above the desk in the Environmental Services Chief Engineer's Office.
3. Observations on 12/14/10, revealed mixed quick response and standard response sprinkler heads in the Business Office.
4. Observations on 12/14/10, revealed a missing escutcheon ring in the Employee Lounge above the refrigerator.
5. Observations on 12/14/10, revealed the facility failed to maintain an 18 inch clearance for the sprinkler heads in the Xray Room.

Maintenance Staff A verified these observations.

(A)
Based on observation, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. This could affect the operation of the heads by obstructing the spray patterns and delaying the response time and causing the heads to be inoperable. This facility has a capacity of 25 patients and a census of 11.

Findings include:

1. Observations on 12/14/10, revealed a corroded sprinkler head in the walk-in cooler in the Kitchen.
2. Observations on 12/14/10, revealed dust build-up on the sprinkler head by the tray return area in the Main Dining Room.
3. Observations on 12/14/10, revealed a dirty sprinkler head by the General Registry Desk Outpatient Window.
4. Observations and record review on 12/14/10, revealed an obstructed sprinkler head (by a wall partition) in the Main Reception Area.

Maintenance Staff A verified these observations.

(B)
Based on record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. This deficient practice could affect all occupants of the facility. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

During record review of the fire safety components on 12/14/10, a report by the sprinkler inspection company dated 2/25/09 reported the following comments: "main drain to floor drain-will not handle full flow." Riser flow pressure marked N/A on the last documented flow pressure check. The last full flow test was dated 6/4/07.

Maintenance Staff A verified these observations.

Based on observations, the facility failed to provide drapery, curtains, and window blinds with provisions of National Fire Protection Association (NFPA) Standard 101 10.3. Based on observation and interview, the facility could not provide documentation that the window blinds were flame resistant. The facility has a capacity of 25 and at the time of the survey the census was 11 patients.

Findings include:

Observations of the mini blinds in the office of the Surgery Section on 12/14/10, revealed they were not metal or aluminum and were not tagged as being flame retardant.

Based on observation, the facility failed to vent the clothes dryer to the outside in the Clinic Basement.

Observations on 12/14/10, revealed the facility failed to vent the clothes dryer to the outside of the building, instead it was being vented into a sock in the room. Maintenance Staff A verified this observation.

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 facility has a capacity of 25 and a census of 11 patients.

Findings include:

1. Observations on 12/14/10, revealed a brown extension cord for the tabletop Christmas tree in the Main Waiting Area in the Clinic.
2. Observations on 12/14/10, revealed an extension cord in the Coding Department.
3. Observations on 12/14/10, revealed obstructed electrical panels in the basement of the Clinic.
4. Observations on 12/14/10, revealed the outlet next to the sink in the Clinic Laundry Room was not a GFCI outlet.
5. Observation on 12/14/10, revealed extension cords in the Electric Phone Room in the basement of the Clinic.
6. Observations on 12/14/10, revealed loose junction boxes on the northwest wall in the Boiler Room.
7. Observations on 12/14/10, revealed viewing lamps in the Dark Room plugged into a surge protector.
8. Observations on 12/14/10, revealed a damaged electrical cord on the white light in the Dark Room.

Maintenance Staff A verified these observations.

Based on record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and patients. This facility has a capacity of 25 with a census of 11 patients.

Findings include:

When reviewing this outage policy on 12/14/10, it stated the following: "down four hours or more", missing the wording "in a 24 hour period; "30 minute rounds" missing the word "continuous"; and contained the phone number 712-262-5849 but should be 515-725-6145. Maintenance Staff A verified these observations.

Based on record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and patients. This facility has a capacity of 25 with a census of 11 patients.

Findings include:

When reviewing this outage policy on 12/14/10, it stated the following: "down four hours or more", missing the wording "in a 24 hour period; "30 minute rounds" missing the word "continuous"; and contained the phone number 712-262-5849 but should be 515-725-6145. Maintenance Staff A verified these observations.

Based on observation, it was determined the facility is a one-story building and consisted of a non-combustible type II (222) protected building. The facility failed to assure minimum building construction requirements were maintained. This facility has a capacity of 25 patients and at the time of the survey the census was 11.

Findings include:

1. Observations on 12/14/10, revealed numerous holes in the ceiling of the Clinic Basement.
2. Observations on 12/14/10, revealed gaps around penetrations above the Medical Vac Pump Station.
3. Observations on 12/14/10, revealed holes in the Storage Area in the Clinic.

Maintenance Staff A verified these observations.

Based on surveyor observation, the facility is not ensuring that doors to resident rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. This facility has a capacity of 25 and a census of 11 .

Findings include:

1. Observations on 12/14/10, revealed the corridor door to the Dumb Waiter Closet on the lower level did not close and latch properly when tested.
2. Observations on 12/1/4/10, revealed the OB Utility Hall corridor door did not close and latch properly when tested.
3. Observations on 12/14/10, revealed the corridor door the the Hospice Room was propped open with a wedge.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain smoke doors to close and resist the passage of smoke. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

Observations on 12/14/10, revealed the smoke doors located next to the physician's lounge would not close and latch properly when tested. Maintenance Staff A verified this observation.

Based on observations, the facility failed to provide separation of hazardous areas from other compartments. The facility has a capacity of 25 and at the time of the survey the census was 11 patients.

Findings include:

1. Observations on 12/14/10, revealed multiple pipe penetrations with gaps (ranging from 1/8 inch to 1/2 inch in size) on the corridor wall of the Oxygen Storage Room on the lower level.
2. Observations on 12/14/10, revealed the absence of a self-closing device on the corridor door to the Oxygen Storage Room on the lower level.
3. Observations on 12/14/10, revealed a hole (approximately 3 inches in size), multiple pipe penetration with gaps around them (ranging in size from 1/4 inch to 1 inch), and some gaps around penetrations filled with foam insulation instead of fire caulk in the South End Hall Storage Room by the elevator equipment room on the lower level.
4. Observations on 12/14/10, revealed no self-closure on the corridor door to Purchasing.
5. Observations on 12/14/10, revealed gaps above the north doors of Purchasing.
6. Observations on 12/14/10, revealed the corridor door to the Laundry Room in the Clinic did not close and latch properly when tested. This door was also propped open with a scale.

Maintenance Staff A verified these observations.

(A)
Based on observation, the facility is not providing unobstructed corridors that provides a clear path of egress in the lower level. This facility is not providing a clear and unobstructed corridor. This facility has a census of 11 and a capacity of 25 patients.

Findings include:

Observations on 12/14/10, revealed numerous items being stored in the South Lower Level Corridor which leads to the outdoors. Maintenance Staff A verified this observation.

(B)
Based on observations, the facility failed to maintain exits readily accessible at all times in accordance with 7.1. This deficient practice could affect occupants utilizing the Lower Level. This facility has a capacity of 25 patients and a census of 11.

Findings include:

1. Observations on 12/14/10, revealed a dealbolt lock for the South Exterior Exit Hallway on the Lower Level. Opening this door requires a person to unlock the deadbolt before turning the handle to exit, thus requiring a double action instead of the required single action.
2. Observations on 12/14/10, revealed the absence of panic hardware on the South Double Doors located by the elevator equipment room. These doors lead into the exit access which then goes outdoors. According the the facilities layout, this is a marked and required exit.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the exit discharge lighting so that the failure of one bulb would not leave the path from the facility in darkness. Three exits were equipped with a light fixture just outside the door that only had one light bulb. This facility has a capacity of 25 and a census of 11.

Findings include:

Observations on 12/14/10, revealed the following exits were equipped with a single source of light (bulb): South Lower Level exit stairs, North Stairwell Exit on the main level, and North Center Exit by the chillers on the main level. Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain two emergency lights located in the Clinic. This deficient practice could affect all occupants in the Clinic.

Findings include:

Observations on 12/14/10, revealed the emergency lights located in the following areas of the Clinic did not operate properly when tested: near Dr. K's Office and at the West Exterior Door. Maintenance Staff A verified these observations.

Based on observations, the facility failed to maintain the some exit signs located in the Clinic. This deficient practice could affect all occupants of the Clinic.

Findings include:

Observations on 12/14/10, revealed the exit signs in the following areas of the Clinic were not properly illuminated: near Dr. K's Office, at the west exterior exit door, and near Exam Room 8A. Maintenance Staff A verified these observations.

Based upon record review, the facility is not conducting fire drills at varied times on each shift. This has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. This facility has a capacity of 25 patients and a census of 11.

Findings include:

Review of the facilities fire drill records on 12/14/10, revealed that fire drills on the second shift had all been conducted between the hours of 1545 and 1610, and all the fire drills on the third shift between the hours of 0652 and 0658. The facility was also missing a drill for the fourth quarter on third shift. Maintenance Staff A verified these observations.

Based on observation, the facility failed to properly protect and label the primary power supply for the fire alarm system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, 1-5.2.5.2. This deficient practice affects all occupants of the building. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

Observations on 12/14/10, revealed the circuit breaker for the fire alarms primary power supply was located in electrical panel NLSA (breaker #20) . The circuit breaker was not mechanically protected and was not properly labeled. Maintenance Staff A verified this observation.

Based on observation, this facility is not assuring that the fire alarm system is installed and maintained in accordance with the National Fire Protection Association (NFPA) 72, 2-3.5, which requires that smoke detectors are not placed with direct airflow, nor closer than three feet to air supply or air return. Installation of smoke detectors close to a ceiling fan/air supply/air return can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 25 and a census of 7 .

Findings include:

1. Observations on 12/14/10, revealed the following areas had smoke detectors located within three feet of an air supply, air return or ceiling fan: Community Relation/Endowment Office, Human Resource Assistant/Auxiliary Office, Feeding Clinic, PT Hallway, Mammography Room, Ultrasound Room, Conference Room 2 (2 detectors), Purchasing by Karen's Desk, Lynette's Office, and Respiratory Therapy (near entrance door). Maintenance Staff A verified these observations.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, 1998 edition. This facility has a capacity of 25 patients and a census of patients.

Findings include:

1. Observations on 12/14/10 , revealed mixed quick response and standard response sprinkler heads in the reception/waiting area of Community Home Health.
2. Observations on 12/14/10, revealed a missing escutcheon ring above the desk in the Environmental Services Chief Engineer's Office.
3. Observations on 12/14/10, revealed mixed quick response and standard response sprinkler heads in the Business Office.
4. Observations on 12/14/10, revealed a missing escutcheon ring in the Employee Lounge above the refrigerator.
5. Observations on 12/14/10, revealed the facility failed to maintain an 18 inch clearance for the sprinkler heads in the Xray Room.

Maintenance Staff A verified these observations.

(A)
Based on observation, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. This could affect the operation of the heads by obstructing the spray patterns and delaying the response time and causing the heads to be inoperable. This facility has a capacity of 25 patients and a census of 11.

Findings include:

1. Observations on 12/14/10, revealed a corroded sprinkler head in the walk-in cooler in the Kitchen.
2. Observations on 12/14/10, revealed dust build-up on the sprinkler head by the tray return area in the Main Dining Room.
3. Observations on 12/14/10, revealed a dirty sprinkler head by the General Registry Desk Outpatient Window.
4. Observations and record review on 12/14/10, revealed an obstructed sprinkler head (by a wall partition) in the Main Reception Area.

Maintenance Staff A verified these observations.

(B)
Based on record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. This deficient practice could affect all occupants of the facility. This facility has a capacity of 25 and a census of 11 patients.

Findings include:

During record review of the fire safety components on 12/14/10, a report by the sprinkler inspection company dated 2/25/09 reported the following comments: "main drain to floor drain-will not handle full flow." Riser flow pressure marked N/A on the last documented flow pressure check. The last full flow test was dated 6/4/07.

Maintenance Staff A verified these observations.

Based on observations, the facility failed to provide drapery, curtains, and window blinds with provisions of National Fire Protection Association (NFPA) Standard 101 10.3. Based on observation and interview, the facility could not provide documentation that the window blinds were flame resistant. The facility has a capacity of 25 and at the time of the survey the census was 11 patients.

Findings include:

Observations of the mini blinds in the office of the Surgery Section on 12/14/10, revealed they were not metal or aluminum and were not tagged as being flame retardant.

Based on observation, the facility failed to vent the clothes dryer to the outside in the Clinic Basement.

Observations on 12/14/10, revealed the facility failed to vent the clothes dryer to the outside of the building, instead it was being vented into a sock in the room. Maintenance Staff A verified this observation.

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 facility has a capacity of 25 and a census of 11 patients.

Findings include:

1. Observations on 12/14/10, revealed a brown extension cord for the tabletop Christmas tree in the Main Waiting Area in the Clinic.
2. Observations on 12/14/10, revealed an extension cord in the Coding Department.
3. Observations on 12/14/10, revealed obstructed electrical panels in the basement of the Clinic.
4. Observations on 12/14/10, revealed the outlet next to the sink in the Clinic Laundry Room was not a GFCI outlet.
5. Observation on 12/14/10, revealed extension cords in the Electric Phone Room in the basement of the Clinic.
6. Observations on 12/14/10, revealed loose junction boxes on the northwest wall in the Boiler Room.
7. Observations on 12/14/10, revealed viewing lamps in the Dark Room plugged into a surge protector.
8. Observations on 12/14/10, revealed a damaged electrical cord on the white light in the Dark Room.

Maintenance Staff A verified these observations.

Based on record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and patients. This facility has a capacity of 25 with a census of 11 patients.

Findings include:

When reviewing this outage policy on 12/14/10, it stated the following: "down four hours or more", missing the wording "in a 24 hour period; "30 minute rounds" missing the word "continuous"; and contained the phone number 712-262-5849 but should be 515-725-6145. Maintenance Staff A verified these observations.

Based on record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could affect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building including staff, visitors and patients. This facility has a capacity of 25 with a census of 11 patients.

Findings include:

When reviewing this outage policy on 12/14/10, it stated the following: "down four hours or more", missing the wording "in a 24 hour period; "30 minute rounds" missing the word "continuous"; and contained the phone number 712-262-5849 but should be 515-725-6145. Maintenance Staff A verified these observations.