HospitalInspections.org

Based on observation and staff interview the facility failed to maintain the proper 2 hour fire resistive ratings for occupancies as described in the Life Safety Code (NFPA 101) 2012 edition section 19.1.3.3. This deficient practice could allow for the transfer of smoke or fire from another occupancy and affect an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations revealed there was no fire resistive rating on the cross corridor doors of the 2 hour fire barrier separating the long term care from the hospital.

This deficient conditions was confirmed by the Maintenance Supervisor.

Based on observation and staff interview the facility failed to maintain a 2 hour fire barrier from an outpatient clinic as required by NFPA 101 (12) section 19.1.3.4.1. This deficient practice could allow for the spread of fire or smoke between occupancies affecting all 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations revealed penetrations in the gypsum and a non self closing attic access door in the fire barrier between the clinic and ambulance bay of the hospital.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on observation and staff interview the facility failed to maintain a stair enclosure in accordance with NFPA 101 (12), Life Safety Code section 7.2.2.5.3.2. This deficient practice could allow for the spread of smoke or fire in the enclosure preventing exiting of an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations revealed the under stair storage was accessed inside the stair enclosure.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on observation and staff interview, the facility failed to provide fire resistance to 2 stair enclosures as described in the 2012 edition of the Life Safety Code, NFPA 101, table 8.3.4.2. This deficient practice could allow for smoke or flame to migrate to another floor affecting an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations revealed the east wing and center stair enclosures did not have fire resistive labels on the doors.

This deficient condition was confirmed by the Maintenance Supervisor

Based on observation and staff interview the facility failed to maintain six hazardous storage room in accordance with the 2012 Life Safety Code (NFPA 101) section 19.3.2.1.3. This deficient condition could allow smoke or fire to enter the corridor making it untenable and affect the quick and efficient exiting for an undetermined amount of staff and visitors

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations and staff interview revealed the following.

1. The lower level storage room door, adjacent to the kitchen, did not latch.
2. The X-ray storage room door on the lower level did not self close.
3. The nurses locker room/storage did not have a self closing door.
4. The storage room adjacent to the housekeeping office did not have a self closing door.
5. The wood working/storage room was not sprinkled and did not meet the 1 hour rating due to several holes in the one hour ceiling, 2 transfer ducts in the one hour wall and a 45 minute self closing door is required.
6. The central supply room door on the lower level did not self close.

This deficient conditions was confirmed by the Maintenance Supervisor.

Based on documentation review and staff interview the facility failed to inspect the cooking equipment, every six months, as stated in the Life Safety Code (NFPA 101) 2012 edition section 9.2.3 & NFPA 96 section 11.2. This deficient practice could allow for the spread of fire if the hood suppression system did not operate properly, affecting an undetermined amount of staff and visitors.

Findings include:

During the facility tour between 7:30 am to 11:00 am on 05/30/2018 record review revealed only one inspection of the hood was conducted in the last 12 months.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on observations and staff interview the facility failed to install the smoke detection in accordance with NFPA 101 Life Safety Code (2012) section 19.3.4.1, 9.6.1.3 and NFPA 72 National Fire Alarm Code (2010) section 17.7.4.1. This deficient practice could affect the ability of the alarm system to sound in a timely manner during a fire event which could affect all patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations revealed a smoke detector within 36 inches of an HVAC diffuser.

This deficient conditions was confirmed by the Maintenance Supervisor.

Based on observations and staff interview the facility failed to maintain the fire alarm system in accordance with NFPA 101 (12) Life Safety Code section 19.3.4.3.1. This deficient practice could delay the notification of a fire for an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations revealed the notification devices, visual and audible, on the lower level were not operable.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the 2012 Life Safety Code (NFPA 101) and NFPA 25 section 5.2.1.1.2. The standard for testing and maintenance of sprinkler systems. This deficient condition could cause the sprinkler system not to function properly and allow for the spread of fire. This could affect all of the 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 documentation review revealed there was no record of an pipe obstruction inspection in the last 5 years.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on observation and staff interview the facility failed to maintain a smoke barrier as required by the 2012 Life Safety Code (NFPA 101) section 19.3.7.3, 8.8.7.1 (1). This deficient practice could allow smoke to transfer from one smoke compartment to another affecting the exiting all 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations revealed the smoke barrier by the nurses station did not use the proper fire stop material along the ceiling line above the cross corridor doors.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on documentation review and staff interview the facility failed to conduct inspections of all fire rated doors and required by NFPA 101 (12) Life Safety Code, section 7.2.1.15.2 & 7.2.1.15.4. This deficient practice could allow for the spread of fire if the doors were not maintained in accordance with its rating. This could affect all 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 documentation review revealed there was no record of inspections for the fire rated doors in the last 12 months.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on observation and staff interview, the facility has failed to provide a complete and current facility Risk Assessment in accordance with the NFPA 99 "Health Care Facilities Code" 2012 edition section 4.1. This deficient practice could affect all patients, as well as an undetermined number of staff, and visitors.

Findings include:

On the facility tour, between 7:30 am to 11:00 am on 05/30/2018, during record review the facility was not able to provide a risk assessment document based on NFPA 99.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on observation and staff interview the facility failed to ensure the generator safety features were in compliance with the 2010 edition of NFPA 110 section 5.6.5.6. This deficient practice could cause the premature failure of the generator which could affect all 15 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations revealed the emergency shut off button on the generator was not located outside of the enclosure.

This deficient conditions was confirmed by the Maintenance Supervisor.

Based on observation and staff interview the facility failed to maintain electrical equipment in accordance with NFPA 101, the Life Safety Code (12) section 9.1.2 and NFPA 70 (11) The National Electrical Code, chapter 300. This deficient practice could allow for potential shock or fire from the electrical device, affecting an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 11:00 am on 05/30/2018 observations revealed a receptacle connected to the building wiring was not secured inside of a box leaving it exposed to human touch or accidental shorting.

This deficient condition was confirmed by the Maintenance Supervisor.