HospitalInspections.org

Based on observation and interview, the facility is not ensuring that doors to rooms are free of impediments that would prevent the door from closing tightly into the door frame. As the doors would not prevent the spread of fire and smoke. This facility has a capacity of 125 and a census of 30 residents.

Findings include:

1. Observation on 8/28/12 at approximately 9:51 a.m., revealed that the MMSC 2nd Floor Break room door failed to close and positively latch.

Maintenance Staff (B) verified these observations.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area could affect approximately 10 staff members. The facility has 125 certified beds and at the time of the survey the census was 30.

Findings include:

Observation and interview of the Soiled Linen room in the north wall on 8-28-12 at approximately 9:50 a.m., revealed that the north wall contained a two feet by three feet hole. Also the wall contain four pipes with approximately two inch gaps around the pipes.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This area could affect all residents, staff members and visitors. The facility has 125 certified beds and at the time of the survey the census was 30.

Findings include:

1. Observation and interview of the MMSC, 3rd floor Elevator Equipment room in the north wall on 8/28/12 at approximately 9:35 a.m., revealed that the north wall contained an 1/2 inch gap around a flexible conduit.
2. Observation and interview of the MMSC, 1st floor Mechanical room in the north wall on 8/28/12 at approximately 9:26 a.m., revealed that the north wall contained 2 red wires with a 1/2 inch gap around the wires.
3. Observation and interview of the MMSC, 1st floor Mechanical room in the north wall on 8/28/12 at approximately 9:26 a.m., revealed that the north wall contained 2 three inches open conduits.
4. Observation and interview of the Rehabilitation Center on 8/28/12 at approximately 10:35 a.m., revealed that the 30 feet by 60 feet storage room that contained flammable records was not equipped with a self-closing device on the corridor door.
Maintenance Staff (B) verified this observation.

Based on observation, staff interview and record review this facility is not providing unobstructed corridors that provides a clear path of egress. This facility has a capacity of 125 with a census of 30.

Findings include:

Observation and interview on 8/28/12 at 11:00 a.m., revealed that the South East exit door at the Conrad Clinic was blocked by tables and chairs. The corridor was not maintained to be clear and unobstructed.

Maintenance Staff (B) verified the observation. According to the facility layout, this was a required exit.

Based on observation and interview, the facility failed to maintain the emergency egress lighting. This deficient practice affects one of one smoke compartments and all occupants of the facility. This facility has a capacity of 125 and a census of 30 residents.

Findings include:

Observation and interview on 8/28/12, revealed that the emergency battery lighting system in the North Restroom of the Tama-Toledo Clinic failed to function when tested.

Maintenance Staff (B) verified this observation.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed 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. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 125 and a census of 30 residents.

Findings include:

Observations on 08-28-12, the following areas had air diffusers that were located within three feet of the smoke detectors:
1. Smoke detector next to air diffuser in the corridor 4th floor 1914 Building next to the Account Tech room.
2. Smoke detector next to air diffuser in the 1914 Building in the Laundry Break room.
3. Smoke detector next to air diffuser in the 1914 Building in the Laboratory Break room.
4. Smoke detector next to air diffuser in the 1962 Building on the ceiling over the ICU Nurses Station.

Maintenance Staff (A) verified these observations.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed 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. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 125 and a census of 30 residents.

Findings include:

Observations on 8-28-12, the following areas had air diffusers that were located within three feet of the smoke detectors:
1. Smoke detector next to air diffuser in the MMSC Clinic 1st Floor Insurance Office.
2. Smoke detector next to air diffuser in the MMSC Clinic 1st Floor Break room.
3. Smoke detector next to air diffuser in the MMSC Clinic 1st Floor Office #3 and Office #4.
4. Smoke detector next to air diffuser in the MMSC Clinic 3rd Floor Exam Room #4,Exam Room #5, Procedure Room, Office #1, Office #2 and Exam Room #12.
5. Smoke detector next to air diffuser in all areas in the Tama-Toledo Clinic.

Maintenance Staff (B) verified these observations.

Based on observation and 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 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. This deficient practice affects all occupants including staff, visitors and residents in one smoke zones. The facility had a capacity of 125 and a census of 30 at the time of survey.

Findings include:

Observations and interview on 08/28/12 at approximately 10:25 a.m., revealed that at the Rehabilitation Center in Exam room #3 one of one sprinkler heads was coated with paint that covered nearly one-half of the deflector and the fusible link.

Maintenance Staff (B) verified this observation.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 125 and a census of 30 at the time of the survey.

Findings Include:

1. Observations and interview on 8-28-12 at 10:26 a.m., revealed the facility failed to maintain the electrical system in the Rehabilitation Center Mechanical room. In the Mechanical Room next to the south wall there was a open electrical junction box with exposed wires.
2. Observations and interview on 8-28-12 at 11:07 a.m., revealed the facility failed to maintain the electrical system in the Conrad Clinic Old Restroom. In the Old Restroom on the ceiling there was a open electrical junction box with exposed wires.
3. Observations and interview on 8-28-12, revealed the facility failed to maintain the electrical system in the State Center Clinic. In the Basement Furnace Room along the ceiling there was a open electrical junction box with exposed wires.

Maintenance Staff (B)verified these observations.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 125 and a census of 30 at the time of the survey.

Findings Include:

1. Observations on 8-28-12 at 9:53 a.m., revealed the facility failed to maintain the electrical system in the Laundry Room Proper located on the west wall next to the windows there was an Electrical Junction Box with exposed wires.
2. Observations on 8-28-12 at 10:09 a.m., revealed the facility failed to maintain the electrical system in the E.R. Mechanical room Panel MT-8B breaker locations #13 and #15 were open with exposed wires.
3. Observations on 8-28-12 at 10:40 a.m., revealed the facility failed to maintain the electrical system in the Kitchen Dish Wash area Panel K-3 breaker locations #17 was open with exposed wires.

Maintenance Staff (A) verified these observations.

Based on observation and interview, the facility is not ensuring that doors to rooms are free of impediments that would prevent the door from closing tightly into the door frame. As the doors would not prevent the spread of fire and smoke. This facility has a capacity of 125 and a census of 30 residents.

Findings include:

1. Observation on 8/28/12 at approximately 9:51 a.m., revealed that the MMSC 2nd Floor Break room door failed to close and positively latch.

Maintenance Staff (B) verified these observations.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area could affect approximately 10 staff members. The facility has 125 certified beds and at the time of the survey the census was 30.

Findings include:

Observation and interview of the Soiled Linen room in the north wall on 8-28-12 at approximately 9:50 a.m., revealed that the north wall contained a two feet by three feet hole. Also the wall contain four pipes with approximately two inch gaps around the pipes.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This area could affect all residents, staff members and visitors. The facility has 125 certified beds and at the time of the survey the census was 30.

Findings include:

1. Observation and interview of the MMSC, 3rd floor Elevator Equipment room in the north wall on 8/28/12 at approximately 9:35 a.m., revealed that the north wall contained an 1/2 inch gap around a flexible conduit.
2. Observation and interview of the MMSC, 1st floor Mechanical room in the north wall on 8/28/12 at approximately 9:26 a.m., revealed that the north wall contained 2 red wires with a 1/2 inch gap around the wires.
3. Observation and interview of the MMSC, 1st floor Mechanical room in the north wall on 8/28/12 at approximately 9:26 a.m., revealed that the north wall contained 2 three inches open conduits.
4. Observation and interview of the Rehabilitation Center on 8/28/12 at approximately 10:35 a.m., revealed that the 30 feet by 60 feet storage room that contained flammable records was not equipped with a self-closing device on the corridor door.
Maintenance Staff (B) verified this observation.

Based on observation, staff interview and record review this facility is not providing unobstructed corridors that provides a clear path of egress. This facility has a capacity of 125 with a census of 30.

Findings include:

Observation and interview on 8/28/12 at 11:00 a.m., revealed that the South East exit door at the Conrad Clinic was blocked by tables and chairs. The corridor was not maintained to be clear and unobstructed.

Maintenance Staff (B) verified the observation. According to the facility layout, this was a required exit.

Based on observation and interview, the facility failed to maintain the emergency egress lighting. This deficient practice affects one of one smoke compartments and all occupants of the facility. This facility has a capacity of 125 and a census of 30 residents.

Findings include:

Observation and interview on 8/28/12, revealed that the emergency battery lighting system in the North Restroom of the Tama-Toledo Clinic failed to function when tested.

Maintenance Staff (B) verified this observation.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed 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. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 125 and a census of 30 residents.

Findings include:

Observations on 08-28-12, the following areas had air diffusers that were located within three feet of the smoke detectors:
1. Smoke detector next to air diffuser in the corridor 4th floor 1914 Building next to the Account Tech room.
2. Smoke detector next to air diffuser in the 1914 Building in the Laundry Break room.
3. Smoke detector next to air diffuser in the 1914 Building in the Laboratory Break room.
4. Smoke detector next to air diffuser in the 1962 Building on the ceiling over the ICU Nurses Station.

Maintenance Staff (A) verified these observations.

Based on observation and interview, this facility is not assuring that the fire alarm system is installed 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. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 125 and a census of 30 residents.

Findings include:

Observations on 8-28-12, the following areas had air diffusers that were located within three feet of the smoke detectors:
1. Smoke detector next to air diffuser in the MMSC Clinic 1st Floor Insurance Office.
2. Smoke detector next to air diffuser in the MMSC Clinic 1st Floor Break room.
3. Smoke detector next to air diffuser in the MMSC Clinic 1st Floor Office #3 and Office #4.
4. Smoke detector next to air diffuser in the MMSC Clinic 3rd Floor Exam Room #4,Exam Room #5, Procedure Room, Office #1, Office #2 and Exam Room #12.
5. Smoke detector next to air diffuser in all areas in the Tama-Toledo Clinic.

Maintenance Staff (B) verified these observations.

Based on observation and 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 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. This deficient practice affects all occupants including staff, visitors and residents in one smoke zones. The facility had a capacity of 125 and a census of 30 at the time of survey.

Findings include:

Observations and interview on 08/28/12 at approximately 10:25 a.m., revealed that at the Rehabilitation Center in Exam room #3 one of one sprinkler heads was coated with paint that covered nearly one-half of the deflector and the fusible link.

Maintenance Staff (B) verified this observation.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 125 and a census of 30 at the time of the survey.

Findings Include:

1. Observations and interview on 8-28-12 at 10:26 a.m., revealed the facility failed to maintain the electrical system in the Rehabilitation Center Mechanical room. In the Mechanical Room next to the south wall there was a open electrical junction box with exposed wires.
2. Observations and interview on 8-28-12 at 11:07 a.m., revealed the facility failed to maintain the electrical system in the Conrad Clinic Old Restroom. In the Old Restroom on the ceiling there was a open electrical junction box with exposed wires.
3. Observations and interview on 8-28-12, revealed the facility failed to maintain the electrical system in the State Center Clinic. In the Basement Furnace Room along the ceiling there was a open electrical junction box with exposed wires.

Maintenance Staff (B)verified these observations.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 125 and a census of 30 at the time of the survey.

Findings Include:

1. Observations on 8-28-12 at 9:53 a.m., revealed the facility failed to maintain the electrical system in the Laundry Room Proper located on the west wall next to the windows there was an Electrical Junction Box with exposed wires.
2. Observations on 8-28-12 at 10:09 a.m., revealed the facility failed to maintain the electrical system in the E.R. Mechanical room Panel MT-8B breaker locations #13 and #15 were open with exposed wires.
3. Observations on 8-28-12 at 10:40 a.m., revealed the facility failed to maintain the electrical system in the Kitchen Dish Wash area Panel K-3 breaker locations #17 was open with exposed wires.

Maintenance Staff (A) verified these observations.