HospitalInspections.org

Based on observation and interview, the facility was a Type I/Type II building construction and the facility failed to provide/maintain interior walls/partitions that were built with noncombustible or limited combustible materials in accordance with Section 19.1.6.3 of the 2000 Life Safety Code. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 06/25/15 at 1:25 pm, revealed an area (approximately 4 inches by 5 inches) on the beam by the Riser where the fire protective material had been removed.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain resident room doors in proper working condition to close and latch properly into the door frame with the swing of the door closer in accordance with Section 19.3.6.3.1 of the 2000 Life Safety Code. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 06/25/15 at 3:27 pm, revealed cloth towels that were on the doors to Rooms 106 and 101 that prevented the doors from closing and latching properly when tested.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 06/25/15 at 1:37 pm, revealed the door closing hardware located on the door to the Generator Room was not functioning properly when tested during this survey.
2. Observations and staff interviews on 06/25/15 at 2:40 pm, revealed the door to the MRI Bay Storage Room was not equipped with the required self-closing hardware.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide fire drills for the staff as required by Section 19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.

Findings Include:

Observations, record review and staff interviews on 06/25/15 at 11:50 am, revealed the facility failed to document the times that the quarterly fire drills were conducted. The only documented time was on 05/22/15 at 11:10 pm.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide a fire alarm system that provided proper activation and annunciation that was installed in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition and Sections 19.3.4 and 9.6 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 06/25/15 at 1:41 pm, revealed the room identified as the Old Incinerator Room was not equipped with fire detection.
Maintenance Staff A verified this observation.

Based on observation, record review, and interview, the facility failed to provide/maintain the building ' s sprinkler system in reliable operating condition and/or maintain proper testing and maintenance in accordance with the National Fire Protection Association (NFPA) Standard 25, Inspections, Testing, and Maintenance of Sprinkler Systems, 1998 edition, the NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1998 edition, and Sections 19.7.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.

Findings Include:

1. Observations and staff interviews on 06/25/15 at 1:30 pm, revealed a dirty sprinkler head located by the air compressor in the Basement.
2. Observations and staff interviews on 06/25/15 at 1:40 pm, revealed the absence of sprinkle coverage when the garage door located in the Garage was in the open position.
3. Observations and staff interviews on 06/25/15 at 1:41 pm, revealed the room identified as the Old Incinerator Room was not protect by a sprinkler.
4. Observations and staff interviews on 06/25/15 at 2:00 pm, revealed the sprinkler head located in the IT Employee Restroom had signs of corrosion on it.
5. Observations and staff interviews on 06/25/15 at 2:40 pm, revealed a foreign material on the sprinkler head located in the Xray Consultation Room.
6. Observations and staff interviews on 06/25/15 at 2:45 pm, revealed a foreign material on the sprinkler head located in the Stairway to the Cafeteria and Vending Room.
7. Observations and staff interviews on 06/25/15 at 3:05 PM, revealed a foreign material on the sprinkler head located in the Main Hospital Stairway.
8. Observations and staff interviews on 06/25/15 at 3:10 pm, revealed a foreign material on the sprinkler head located in Room 106.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain the building ' s electrical wiring and equipment in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 06/25/15 at 1:25 pm, revealed items being stored within the required 36 inches of the electric panels located in the Maintenance Shop.
2. Observations and staff interviews on 06/25/15 at 1:25 pm, revealed a missing junction box cover in the Tool Lock Up Room.
Maintenance Staff A verified these observances.

Based on observation and interview, the facility was a Type I/Type II building construction and the facility failed to provide/maintain interior walls/partitions that were built with noncombustible or limited combustible materials in accordance with Section 19.1.6.3 of the 2000 Life Safety Code. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 06/25/15 at 1:25 pm, revealed an area (approximately 4 inches by 5 inches) on the beam by the Riser where the fire protective material had been removed.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain resident room doors in proper working condition to close and latch properly into the door frame with the swing of the door closer in accordance with Section 19.3.6.3.1 of the 2000 Life Safety Code. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 06/25/15 at 3:27 pm, revealed cloth towels that were on the doors to Rooms 106 and 101 that prevented the doors from closing and latching properly when tested.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 06/25/15 at 1:37 pm, revealed the door closing hardware located on the door to the Generator Room was not functioning properly when tested during this survey.
2. Observations and staff interviews on 06/25/15 at 2:40 pm, revealed the door to the MRI Bay Storage Room was not equipped with the required self-closing hardware.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide fire drills for the staff as required by Section 19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.

Findings Include:

Observations, record review and staff interviews on 06/25/15 at 11:50 am, revealed the facility failed to document the times that the quarterly fire drills were conducted. The only documented time was on 05/22/15 at 11:10 pm.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide a fire alarm system that provided proper activation and annunciation that was installed in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition and Sections 19.3.4 and 9.6 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 06/25/15 at 1:41 pm, revealed the room identified as the Old Incinerator Room was not equipped with fire detection.
Maintenance Staff A verified this observation.

Based on observation, record review, and interview, the facility failed to provide/maintain the building ' s sprinkler system in reliable operating condition and/or maintain proper testing and maintenance in accordance with the National Fire Protection Association (NFPA) Standard 25, Inspections, Testing, and Maintenance of Sprinkler Systems, 1998 edition, the NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1998 edition, and Sections 19.7.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.

Findings Include:

1. Observations and staff interviews on 06/25/15 at 1:30 pm, revealed a dirty sprinkler head located by the air compressor in the Basement.
2. Observations and staff interviews on 06/25/15 at 1:40 pm, revealed the absence of sprinkle coverage when the garage door located in the Garage was in the open position.
3. Observations and staff interviews on 06/25/15 at 1:41 pm, revealed the room identified as the Old Incinerator Room was not protect by a sprinkler.
4. Observations and staff interviews on 06/25/15 at 2:00 pm, revealed the sprinkler head located in the IT Employee Restroom had signs of corrosion on it.
5. Observations and staff interviews on 06/25/15 at 2:40 pm, revealed a foreign material on the sprinkler head located in the Xray Consultation Room.
6. Observations and staff interviews on 06/25/15 at 2:45 pm, revealed a foreign material on the sprinkler head located in the Stairway to the Cafeteria and Vending Room.
7. Observations and staff interviews on 06/25/15 at 3:05 PM, revealed a foreign material on the sprinkler head located in the Main Hospital Stairway.
8. Observations and staff interviews on 06/25/15 at 3:10 pm, revealed a foreign material on the sprinkler head located in Room 106.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain the building ' s electrical wiring and equipment in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility had a capacity of 25 residents and a census of 15 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 06/25/15 at 1:25 pm, revealed items being stored within the required 36 inches of the electric panels located in the Maintenance Shop.
2. Observations and staff interviews on 06/25/15 at 1:25 pm, revealed a missing junction box cover in the Tool Lock Up Room.
Maintenance Staff A verified these observances.