HospitalInspections.org

Based on observation and staff interview it was determined the facility failed to provide doors opening to the corridor that would close and latch. This could place 3 residents at risk in the event of a fire in the facility

The findings were:

On 12/13/2013 between 08:45am and 11:00am it was observed doors to resident rooms 208, 216, and 217 did not close and latch when tested.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating. This could place any patient and staff at risk in the event of a fire in the facility.

The findings were:

On 12/13/2013 between 08:45am and 11:00am observation revealed the smoke barrier located in the lab hall was not sealed at the roof deck and had numerous low voltage penetrations.

On 12/13/2013 between 08:45am and 11:00am observation revealed the smoke barrier next to the nurse's station had a conduit penetration housing low voltage wiring.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provide exit signs with continuous illumination. This could place any resident and staff exiting the dining room and any kitchen staff exiting the kitchen during a loss of lighting at risk.

The findings were:

On 12/13/2013 between 08:45am and 11:00am observation revealed that the dining room exits and the kitchen exit was not provided with illuminated exit signs.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provided a fire sprinkler system installed in accordance with NFPA 13. This could place all 7 patients and the staff at risk in the event of a fire in the facility.

The findings were:

On 12/13/2013 between 08:45am and 11:00am observation revealed A, B, and C halls constituting a single compartment in the facility contained a mixture of standard response and quick response fire sprinkler heads.

This finding was confirmed by staff M1 at the time of discovery.

Based on observation and staff interview it was determined the facility failed to protect the cooking equipment in accordance with NFPA 96. This could put the kitchen staff at risk in the event of a grease fire in the facility.

The findings were:

On 12/13/2013 between 08:30am and 11:00am observation revealed the deep fat grease fryer was located within 18" of the gas eyes (open flame) on the stove top.

This finding was confirmed by staff M1 at the time of discovery.

Based on observation, review of facility records, and staff interview it was determined the facility failed to inspect and test the generator in accordance with NFPA 99. This could place all 7 patients and facility staff at risk in the event of a power failure.

The findings were:

During a review of facility records with staff M on 12/13/2013 between 08:45am and 11:00am records revealed the generator was not inspected and excercised for 5 minutes on a weekly basis and the generator was not exercised under load for 30 minutes per month.

These findings were confirmed by staff M1 at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provide doors opening to the corridor that would close and latch. This could place 3 residents at risk in the event of a fire in the facility

The findings were:

On 12/13/2013 between 08:45am and 11:00am it was observed doors to resident rooms 208, 216, and 217 did not close and latch when tested.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating. This could place any patient and staff at risk in the event of a fire in the facility.

The findings were:

On 12/13/2013 between 08:45am and 11:00am observation revealed the smoke barrier located in the lab hall was not sealed at the roof deck and had numerous low voltage penetrations.

On 12/13/2013 between 08:45am and 11:00am observation revealed the smoke barrier next to the nurse's station had a conduit penetration housing low voltage wiring.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provide exit signs with continuous illumination. This could place any resident and staff exiting the dining room and any kitchen staff exiting the kitchen during a loss of lighting at risk.

The findings were:

On 12/13/2013 between 08:45am and 11:00am observation revealed that the dining room exits and the kitchen exit was not provided with illuminated exit signs.

These findings were confirmed by staff M at the time of discovery.

Based on observation and staff interview it was determined the facility failed to provided a fire sprinkler system installed in accordance with NFPA 13. This could place all 7 patients and the staff at risk in the event of a fire in the facility.

The findings were:

On 12/13/2013 between 08:45am and 11:00am observation revealed A, B, and C halls constituting a single compartment in the facility contained a mixture of standard response and quick response fire sprinkler heads.

This finding was confirmed by staff M1 at the time of discovery.

Based on observation and staff interview it was determined the facility failed to protect the cooking equipment in accordance with NFPA 96. This could put the kitchen staff at risk in the event of a grease fire in the facility.

The findings were:

On 12/13/2013 between 08:30am and 11:00am observation revealed the deep fat grease fryer was located within 18" of the gas eyes (open flame) on the stove top.

This finding was confirmed by staff M1 at the time of discovery.

Based on observation, review of facility records, and staff interview it was determined the facility failed to inspect and test the generator in accordance with NFPA 99. This could place all 7 patients and facility staff at risk in the event of a power failure.

The findings were:

During a review of facility records with staff M on 12/13/2013 between 08:45am and 11:00am records revealed the generator was not inspected and excercised for 5 minutes on a weekly basis and the generator was not exercised under load for 30 minutes per month.

These findings were confirmed by staff M1 at the time of discovery.