HospitalInspections.org

Based on surveyor observation and staff interview, the facility failed to maintain smoke barriers to resist the passage of smoke. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and staff interview on 02/18/15 at 10:28 a.m., revealed an approximately 3 foot by 8-inch hole through the smoke barrier above the smoke barrier doors near the Pharmacy.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and staff interview on 02/18/15 revealed the following deficiencies:

1. At 9:27 a.m. the Midwest sprinkler system inspection report dated 02/21/14 stated, "small storage room in ambulance garage hallway isn't properly covered." The facility had not corrected this deficiency at the time of the inspection.
2. At 10:32 a.m. linens in the Linen Closet near the Meditation Room were located within 18-inches of the sprinkler head.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70, 1999 edition. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and staff interview on 02/18/15 at 10:03 a.m., revealed an open electrical junction box located above panel HA-1 in the AHU 6 Room.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain smoke barriers to resist the passage of smoke. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and staff interview on 02/18/15 at 10:28 a.m., revealed an approximately 3 foot by 8-inch hole through the smoke barrier above the smoke barrier doors near the Pharmacy.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and staff interview on 02/18/15 revealed the following deficiencies:

1. At 9:27 a.m. the Midwest sprinkler system inspection report dated 02/21/14 stated, "small storage room in ambulance garage hallway isn't properly covered." The facility had not corrected this deficiency at the time of the inspection.
2. At 10:32 a.m. linens in the Linen Closet near the Meditation Room were located within 18-inches of the sprinkler head.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on surveyor observation and staff interview, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70, 1999 edition. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and staff interview on 02/18/15 at 10:03 a.m., revealed an open electrical junction box located above panel HA-1 in the AHU 6 Room.

Administrative Staff A and Maintenance Staff A observed this finding.