HospitalInspections.org

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 12 patients.

Findings include:

Observation and staff interview on 8/1/16 at 3:20 p.m. revealed the OB Soiled Utility room door and OB Equipment Storage room were equipped with deadbolt action locking mechanisms.
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 three of eight smoke compartments and could affect approximately 40 residents as well as staff. This facility has a capacity of 25 and a census of 12 residents.
Findings include:
Observation and staff interview of the following rooms on 8/1/16 at 2:33 p.m. revealed several holes and penetrations:
1. Mechanical Room #8 contained an open conduit on the East wall
2. Basement Mechanical Room #11 contained four - 3 inch open conduits in the ceiling.
3. Boiler Room contained 3 inch open conduit above the Electrical panel labeled ECRDL1.
Maintenance Staff confirmed these observations during the survey process.

Based on observation and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This facility has a capacity of 25 and a census of 12 residents.

Findings include:

Observation and staff interview on 8/1/16 at 3:12 p.m. revealed the smoke detector in North hall was within one foot of the air supply unit. Maintenance Staff verified the observation during the survey process.

Based on observation, staff interview and record review, the facility failed to maintain and test a complete automatic sprinkler system. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 12.

Findings include:

Observation and record review of the facilities fire safety components on 8/1/16 at 4:17 p.m., revealed that the facility was missing two quarterly checks for 2015 according to the paperwork. Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. The facility had a capacity of 25 and a census of 12 at the time of survey.

Findings include:

Observation and staff interview on 8/1/16 at 2:40 p.m., one of five sprinkler heads located in Room #106 was coated with white paint and had not been replaced.
Maintenance Staff verified this observation during the survey process.

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 12 patients.

Findings include:

Observation and staff interview on 8/1/16 at 3:20 p.m. revealed the OB Soiled Utility room door and OB Equipment Storage room were equipped with deadbolt action locking mechanisms.
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 three of eight smoke compartments and could affect approximately 40 residents as well as staff. This facility has a capacity of 25 and a census of 12 residents.
Findings include:
Observation and staff interview of the following rooms on 8/1/16 at 2:33 p.m. revealed several holes and penetrations:
1. Mechanical Room #8 contained an open conduit on the East wall
2. Basement Mechanical Room #11 contained four - 3 inch open conduits in the ceiling.
3. Boiler Room contained 3 inch open conduit above the Electrical panel labeled ECRDL1.
Maintenance Staff confirmed these observations during the survey process.

Based on observation and staff interview, this facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. This facility has a capacity of 25 and a census of 12 residents.

Findings include:

Observation and staff interview on 8/1/16 at 3:12 p.m. revealed the smoke detector in North hall was within one foot of the air supply unit. Maintenance Staff verified the observation during the survey process.

Based on observation, staff interview and record review, the facility failed to maintain and test a complete automatic sprinkler system. All smoke compartments in the building and all residents and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 12.

Findings include:

Observation and record review of the facilities fire safety components on 8/1/16 at 4:17 p.m., revealed that the facility was missing two quarterly checks for 2015 according to the paperwork. Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview the facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, 2-2.1.1, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. This can effect the operation of the heads by obstructing spray patterns, delay the response time or even cause the heads to be inoperable which can compromise the effectiveness of the fire suppression system and place occupants at risk of injury in the event of a fire. The facility had a capacity of 25 and a census of 12 at the time of survey.

Findings include:

Observation and staff interview on 8/1/16 at 2:40 p.m., one of five sprinkler heads located in Room #106 was coated with white paint and had not been replaced.
Maintenance Staff verified this observation during the survey process.