HospitalInspections.org

Based on record review the facility failed to provide emergency egress lighting in patent procedure rooms. This deficient practice affects patents that are being provided with procedures. This facility has a capacity of 25 a census of 4 residents.

Findings include:

Observation and interview on 5-2-17 at 12:42 p.m. revealed that the battery operated emergency lighting in the procedure rooms were removed during the recent remodeling of the rooms.

Maintenance Staff (A) verified these observations.

Based on observation and interview, the facility is not maintaining the sprinkler system in accordance with the 2011 edition of NFPA 25, 5.2.1.1*, 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 of seven smoke zones. The facility had a capacity of 25 and a census of 4 at the time of survey.

Findings include:

1. Observation and interview on 5-2-17 at approximately 12:20 p.m., revealed that in patent room #103 the ceiling sprinkler head was covered dust.

2. Observation and interview on 5-2-17 at approximately 12:34 p.m., revealed that in patent room #112 two of three ceiling sprinkler heads were covered dust.

Maintenance Staff (A) verified these observations.

Based on observation and interview this facility is not assuring that two of nine smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all staff, visitors and four residents. This facility has a capacity of 25 and a census of 4 residents.

Findings include:

1. Observation and interview on 5-2-2017 at approximately 11:15 a.m., the smoke barrier in the corridor next to the Gift Shop above the lay-in tile ceiling tiles over the smoke doors contained three holes with approximately 1/2 gaps around communication wire penetrations.

2. Observation and interview on 5-2-2017 at approximately 12:07 p.m., the smoke barrier in the corridor next to the Medical Gas Storage room above the lay-in tile ceiling tiles over the smoke doors contained two holes with approximately 1/2 gaps around communication wire penetrations. This smoke barrier also contained a 6 inches sprinkler pipe penetration with a 1/4 inch gap around the pipe.

Maintenance Staff (A) 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, 2011 edition, placing the Staff of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 4 at the time of the survey.

Findings Include:

Observation and interview on 5-2-17 at 11:20 a.m., revealed the facility failed to maintain the electrical system in the Kitchen. The east Accutemp Steamer contained an electrical cord that was not properly connected to the Steamer exposing the cord wiring.

Maintenance Staff (A) verified this observation.

Based on observation and interview, the facility is not storing nitrogen tanks in accordance with NFPA 99, to ensure that tanks were adequately secured to prevent them from accidental damage or dislocation. This deficient practice occurred in one of seven smoke zones. This facility has a capacity of 25 and a census of 4 residents.

Findings include:

Observation and interview on 5-2-17 at approximately 11:30 a.m., the 2nd floor Chiller room contained one large Nitrogen Gas cylinder. The tank was not properly secured to prevent damage.

Maintenance Staff (A) verified this observation.