HospitalInspections.org

Based upon observation and interview, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 4.

Findings include:

Observation and interview on 9/12/11, the facility fire drill documentation showed that all of the third shift drills were conducted within the same hour for all four quarters. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility failed to provided a properly maintained fire alarm system. Staff who uses the Boiler Room were affected by the deficient practice which was in one of four smoke compartments. The facility has 25 certified beds and at the time of the survey the census was 4.

Findings include:

Observation and interview on 9/12/11, revealed that the pull stations located in the Boiler room were approximately 5 feet 4 inches above the floor. These pull stations are required to be between 3 1/2 feet to 4 1/2 feet above the floor according to NFPA 72 2-8.1. Maintenance Staff confirmed these observations at the time of the survey process.

(A)
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 corrosion, paint or other 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 of four smoke zones. The facility had a capacity of 25 and a census of 4 at the time of survey.

Findings include:

Observation and interview on 9/12/11, one sprinkler head located in the Kitchen was coated with white paint. Maintenance Staff verified this observation during the survey process.

(B)
Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. Standard for the installation of Sprinkler Systems, 1999 edition, placing a census of 4 patients at risk in the event of a fire. This facility is cerified for 25 beds.

Findings include:

Observations and interview on 9/12/11, revealed the sprinkler riser did not have a hydraulic name plate. Maintenance Staff verified this observation at the time of the survey.

Based on observation and interview, the facility failed to maintain the paperwork of the emergency generator power supply as required. The deficient practice would affect all smoke compartments of building and all of the residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 4.

Findings include:

Observation and interview on 9/12/11, revealed that proper documentation of the generator weekly and monthly inspections did not provide the start and end run times. Maintenance Staff verified this observation during the survey process.

Based upon observation and interview, the facility failed to hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 4.

Findings include:

Observation and interview on 9/12/11, the facility fire drill documentation showed that all of the third shift drills were conducted within the same hour for all four quarters. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, the facility failed to provided a properly maintained fire alarm system. Staff who uses the Boiler Room were affected by the deficient practice which was in one of four smoke compartments. The facility has 25 certified beds and at the time of the survey the census was 4.

Findings include:

Observation and interview on 9/12/11, revealed that the pull stations located in the Boiler room were approximately 5 feet 4 inches above the floor. These pull stations are required to be between 3 1/2 feet to 4 1/2 feet above the floor according to NFPA 72 2-8.1. Maintenance Staff confirmed these observations at the time of the survey process.

(A)
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 corrosion, paint or other 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 of four smoke zones. The facility had a capacity of 25 and a census of 4 at the time of survey.

Findings include:

Observation and interview on 9/12/11, one sprinkler head located in the Kitchen was coated with white paint. Maintenance Staff verified this observation during the survey process.

(B)
Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. Standard for the installation of Sprinkler Systems, 1999 edition, placing a census of 4 patients at risk in the event of a fire. This facility is cerified for 25 beds.

Findings include:

Observations and interview on 9/12/11, revealed the sprinkler riser did not have a hydraulic name plate. Maintenance Staff verified this observation at the time of the survey.

Based on observation and interview, the facility failed to maintain the paperwork of the emergency generator power supply as required. The deficient practice would affect all smoke compartments of building and all of the residents and staff. The facility has 25 certified beds and at the time of the survey the facility census was 4.

Findings include:

Observation and interview on 9/12/11, revealed that proper documentation of the generator weekly and monthly inspections did not provide the start and end run times. Maintenance Staff verified this observation during the survey process.