HospitalInspections.org

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 lint. 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 5 at the time of survey.

Findings include:

Observation and staff interview on 12/4/15 at 12:29 p.m., revealed three of six sprinkler heads located in the Kitchen were dirty. Maintenance Staff verified this observation during the survey process.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect four out of four smoke compartments and all of the residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 5.

Findings include:

Documentation review and staff interview on 12/4/15 at 11:10 a.m. with Maintenance Staff revealed the facility could not provide documentation to show that the generator was running at 30 percent load of the facility while in a 30 minute monthly test. The start and end times were not logged in the generator paperwork for the weekly and monthly test. Maintenance Staff verified 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 lint. 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 5 at the time of survey.

Findings include:

Observation and staff interview on 12/4/15 at 12:29 p.m., revealed three of six sprinkler heads located in the Kitchen were dirty. Maintenance Staff verified this observation during the survey process.

Based on staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice would affect four out of four smoke compartments and all of the residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 5.

Findings include:

Documentation review and staff interview on 12/4/15 at 11:10 a.m. with Maintenance Staff revealed the facility could not provide documentation to show that the generator was running at 30 percent load of the facility while in a 30 minute monthly test. The start and end times were not logged in the generator paperwork for the weekly and monthly test. Maintenance Staff verified this observation during the survey process.