HospitalInspections.org

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the corridor doors. Findings include:

Corridor doors throughout the facility were observed with self-closing devices and toe-hold open devices, thus impeding the closing of the corridor door. The following are examples:
1. Room 604
2. Room 603
3. Room 602
4. Central Supply Room

This deficiency impacted 6 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 18.3.6.3.3*
Hold-open devices that release when the door is pushed or pulled shall be permitted.

.

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the exit/directional signs. Findings include:

The following locations had exit signs that were misleading in which way to reach an exit:
1. Administration Area
2. By Pharmacy

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the doors in smoke barriers. Findings include:

The door in the smoke barrier separating the Gym and the Activity Room was observed without a self-closing device.

This deficiency impacted 2 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 18.3.7.6* Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the hazardous areas. Findings include:

The Library/Storage Room was over 100 sq. ft. with combustibles. This room did not have a complete one hour rated enclosure per the following observations:
1. The right wall had an unsealed penetration of approximately 1' x 1'.
2. The door was only 20 minute fire-rated per the label.

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 18.3.2.1* Hazardous Areas.
.

.
Based on the review of facility documentation on 06/24/2015, the facility failed to conduct fire drills at unexpected times under varying conditions and provide proof of participation of all on duty staff at the time of the fire drill(s). Findings include:
1. Per documentation provided by the maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.
2. Second/Night Shift (the facility only has two shifts per maintenance staff and drills)
06/19/2015 - 10:07 pm
03/19/2015 - 10:20 pm
12/18/2015 - 9:56 pm
09/17/2014 - 10:00 pm
This deficiency impacted 6 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 4.7.2* Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

Review of 2000 NFPA 101, 19.7.1.2

.

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the single designated smoking area. Findings include:

The single designated smoking area was observed with:
1. A metal container with a non-functioning self-closing cover device
2. No ashtray was provided
3. Excessive smoking material was observed on the ground in pinestraw

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 19.7.4
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to prohibit portable space heating devices in the facility. Findings include:

A portable space heating device was observed plugged into a surge protector (extension cord), but was not turned on in room 427 (located in a sleeping compartment).

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to ensure the fire doors had latching hardware. Findings include:

The fire doors separating the "hospital" from the "residential" did not have latching hardware.

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 1999 NFPA 80, 3-4.1* Swinging tin clad and sheet metal fire doors shall be equipped with self-closing or automatic-closing devices to ensure that they are closed and latched at the time of fire.
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to prohibit portable space heating devices in the facility. Findings include:

A portable space heating device was observed plugged into a surge protector (extension cord), but was not turned on in room 427 (located in a sleeping compartment).

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the corridor doors. Findings include:

Corridor doors throughout the facility were observed with self-closing devices and toe-hold open devices, thus impeding the closing of the corridor door. The following are examples:
1. Room 604
2. Room 603
3. Room 602
4. Central Supply Room

This deficiency impacted 6 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 18.3.6.3.3*
Hold-open devices that release when the door is pushed or pulled shall be permitted.

.

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the exit/directional signs. Findings include:

The following locations had exit signs that were misleading in which way to reach an exit:
1. Administration Area
2. By Pharmacy

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the doors in smoke barriers. Findings include:

The door in the smoke barrier separating the Gym and the Activity Room was observed without a self-closing device.

This deficiency impacted 2 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 18.3.7.6* Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the hazardous areas. Findings include:

The Library/Storage Room was over 100 sq. ft. with combustibles. This room did not have a complete one hour rated enclosure per the following observations:
1. The right wall had an unsealed penetration of approximately 1' x 1'.
2. The door was only 20 minute fire-rated per the label.

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 18.3.2.1* Hazardous Areas.
.

.
Based on the review of facility documentation on 06/24/2015, the facility failed to conduct fire drills at unexpected times under varying conditions and provide proof of participation of all on duty staff at the time of the fire drill(s). Findings include:
1. Per documentation provided by the maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills. Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include signatures of all staff in the facility at the time of the fire drills.
2. Second/Night Shift (the facility only has two shifts per maintenance staff and drills)
06/19/2015 - 10:07 pm
03/19/2015 - 10:20 pm
12/18/2015 - 9:56 pm
09/17/2014 - 10:00 pm
This deficiency impacted 6 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 4.7.2* Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

Review of 2000 NFPA 101, 19.7.1.2

.

.
Based on the observation during the survey on 06/23/2015, the facility failed to maintain the single designated smoking area. Findings include:

The single designated smoking area was observed with:
1. A metal container with a non-functioning self-closing cover device
2. No ashtray was provided
3. Excessive smoking material was observed on the ground in pinestraw

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 19.7.4
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to prohibit portable space heating devices in the facility. Findings include:

A portable space heating device was observed plugged into a surge protector (extension cord), but was not turned on in room 427 (located in a sleeping compartment).

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to ensure the fire doors had latching hardware. Findings include:

The fire doors separating the "hospital" from the "residential" did not have latching hardware.

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 1999 NFPA 80, 3-4.1* Swinging tin clad and sheet metal fire doors shall be equipped with self-closing or automatic-closing devices to ensure that they are closed and latched at the time of fire.
.

.
Based on the observation during the survey on 06/23/2015, the facility failed to prohibit portable space heating devices in the facility. Findings include:

A portable space heating device was observed plugged into a surge protector (extension cord), but was not turned on in room 427 (located in a sleeping compartment).

This deficiency impacted 1 of 6 smoke compartments.
_______________

Review of 2000 NFPA