HospitalInspections.org

Based on observation and interview, 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.
Findings Include:
Observations and staff interviews on 09/24/14, revealed a missing ceiling tile located in the Riser Room on the Second Floor.
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.
Findings Include:
1. Observations and staff interviews on 09/24/14, revealed the door to the Chapel on the 2nd Floor would not close and latch properly when tested during this survey.
2. Observations and staff interviews on 09/24/14, revealed a gap(greater than 1/2 inch between the door and frame located on the door to Exam Room 4 on the 2nd Floor.
3. Observations and staff interviews on 09/24/14, revealed the door to Room 277 on the 2nd Floor did not latch properly when tested during this survey.
4. Observations and staff interviews on 09/24/14, revealed a Hasp Lock located on the Nurses Break Room Door on the 2nd Floor.
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 its 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.
Findings Include:
1. Observations and staff interviews on 09/24/14, revealed a hole on the ceiling located in the IT Workroom.
2. Observations and staff interviews on 09/24/14, revealed the door to the IT Workroom was being propped open.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain exits easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition.
Findings Include:
Observations and staff interviews on 09/24/14, revealed a hasp lock located on the exit door in the Boiler Room.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide the required 30 second every 30 day testing of the emergency lighting units throughout the facility as required by Sections 19.2.9.1 and 7.9 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition.
Observations and staff interviews on 09/24/14, revealed the facility failed to test and document the emergency lights.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide the required number of fire drills for 4 quarters 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.

Findings Include:

Observations and record reviews on 09/24/14, revealed the facility failed to conduct a 4th quarter fire drill for the day shift and did not conduct any fire drills for the night shift.

Maintenance Staff A verified this observation.

Based on record review/observation and interview, the facility failed to maintain a sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition within the facility that was in accordance with that National Fire Protection Association (NFPA) Standard 25, 1998 edition.

Findings Include:

Observations, record review and staff interviews on 09/24/14, revealed the facility failed to conduct and document a required quarterly inspection of its sprinkler system. No documentation was provided for a 4th quarter sprinkler test for 2013.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide proper portable fire extinguishers within the facility that were in accordance with the National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition and Section 19.3.5.6 of the NFPA Standard 101, Life Safety Code, 2000 edition.
Findings Include:
1. Observations and staff interviews on 09/24/14, revealed the fire extinguisher located in the Elevator Mechanical Room was expired and sitting on the floor.
2. Observations and staff interviews on 09/24/14, revealed the fire extinguisher located in the corridor the elevator doors was last inspected on 08/2012.
Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide/maintain the proper testing/weekly inspections required for the building ' s Emergency Generator in accordance with Section 3.4.4.1 of the National Fire Protection Association (NFPA) Standard 99, Standard for Health Care Facilities, and Section 8.4.2 of the NFPA Standard 110, Standard for Emergency and Standby Power Systems, 1999 edition.
Findings Include:
Observations, record review and staff interviews on 09/24/14, revealed the facility was conducting monthly tests for 20 minutes and not documenting the percentage of load.
Maintenance Staff A verified this observation.

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.
Findings Include:
Observations and staff interviews on 09/24/14, revealed the electrical breakers were marked spare and in the on position. This was located throughout the building.

Maintenance Staff A verified this observation.

Based on observation and interview, 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.
Findings Include:
Observations and staff interviews on 09/24/14, revealed a missing ceiling tile located in the Riser Room on the Second Floor.
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.
Findings Include:
1. Observations and staff interviews on 09/24/14, revealed the door to the Chapel on the 2nd Floor would not close and latch properly when tested during this survey.
2. Observations and staff interviews on 09/24/14, revealed a gap(greater than 1/2 inch between the door and frame located on the door to Exam Room 4 on the 2nd Floor.
3. Observations and staff interviews on 09/24/14, revealed the door to Room 277 on the 2nd Floor did not latch properly when tested during this survey.
4. Observations and staff interviews on 09/24/14, revealed a Hasp Lock located on the Nurses Break Room Door on the 2nd Floor.
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 its 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.
Findings Include:
1. Observations and staff interviews on 09/24/14, revealed a hole on the ceiling located in the IT Workroom.
2. Observations and staff interviews on 09/24/14, revealed the door to the IT Workroom was being propped open.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain exits easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition.
Findings Include:
Observations and staff interviews on 09/24/14, revealed a hasp lock located on the exit door in the Boiler Room.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide the required 30 second every 30 day testing of the emergency lighting units throughout the facility as required by Sections 19.2.9.1 and 7.9 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition.
Observations and staff interviews on 09/24/14, revealed the facility failed to test and document the emergency lights.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide the required number of fire drills for 4 quarters 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.

Findings Include:

Observations and record reviews on 09/24/14, revealed the facility failed to conduct a 4th quarter fire drill for the day shift and did not conduct any fire drills for the night shift.

Maintenance Staff A verified this observation.

Based on record review/observation and interview, the facility failed to maintain a sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition within the facility that was in accordance with that National Fire Protection Association (NFPA) Standard 25, 1998 edition.

Findings Include:

Observations, record review and staff interviews on 09/24/14, revealed the facility failed to conduct and document a required quarterly inspection of its sprinkler system. No documentation was provided for a 4th quarter sprinkler test for 2013.

Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to provide proper portable fire extinguishers within the facility that were in accordance with the National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition and Section 19.3.5.6 of the NFPA Standard 101, Life Safety Code, 2000 edition.
Findings Include:
1. Observations and staff interviews on 09/24/14, revealed the fire extinguisher located in the Elevator Mechanical Room was expired and sitting on the floor.
2. Observations and staff interviews on 09/24/14, revealed the fire extinguisher located in the corridor the elevator doors was last inspected on 08/2012.
Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide/maintain the proper testing/weekly inspections required for the building ' s Emergency Generator in accordance with Section 3.4.4.1 of the National Fire Protection Association (NFPA) Standard 99, Standard for Health Care Facilities, and Section 8.4.2 of the NFPA Standard 110, Standard for Emergency and Standby Power Systems, 1999 edition.
Findings Include:
Observations, record review and staff interviews on 09/24/14, revealed the facility was conducting monthly tests for 20 minutes and not documenting the percentage of load.
Maintenance Staff A verified this observation.

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.
Findings Include:
Observations and staff interviews on 09/24/14, revealed the electrical breakers were marked spare and in the on position. This was located throughout the building.

Maintenance Staff A verified this observation.