HospitalInspections.org

Based on observations made on July 23, 2013, the facility failed to assure that a corridor door was not impeded from closing and latching and was capable of being opened with less than 30 pounds of force being applied to the door. This deficiency has the potential to affect a very limited number of residents, staff and visitors in one of the two smoke compartments of the building.

The findings include:

The forces required to fully open any door manually in a means of egress shall not exceed 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width per section 7.2.1.4.5 of the Life Safety Code .

The corridor door to nursing home room 28 was exercised at 12:17 p.m. on July 23, 2013. Due to warping of the corridor door the door was impeded from closing easily. Once closed the door was exercised for its ability to open. Due to the warping of the door it was wedged with the frame and required over 30 pounds of force set it in motion.

Based on observations made on July 23, 2013, the facility failed to assure that doors protecting hazardous areas closed and latched with the efforts of the self-closing mechanism. This deficiency has the potential to affect more than a very limited number of residents, staff and visitors in one of the two smoke compartments of the building.

The findings include:

The 3 hour rated fire corridor door to the nursing home main soiled linen holding room was exercised at 12:55 p.m. on July 23, 2013. The self-closing mechanism on the door did not return it to a latch when closed.

Based on review of the fire drill reports at the facility on July 23, 2013, the facility failed to assure that fire drills were held at least quarterly on all shifts. This deficiency has the potential to affect all residents, patients, visitors and staff in the building.

The findings include:

The facility has three shifts, with the night shift hours being 10 p.m. to 6 a.m. in both the Nursing Home and the Critical Access Hospital. No documentation was available that a fire drill had been held during those hours for the night shift during the second quarter (April, May, June) of 2013.

Based on observations made on July 23, 2013, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies have the potential to affect more than a very limited number of residents, staff and visitors in one of the two smoke compartments of the building.

The findings include:

Equipment intended to interrupt current at fault levels (Ground-Fault Circuit-Interrupter receptacles or GFCI) shall have an interrupting rating sufficient for the nominal circuit voltage and the current available at the line terminals of the equipment (Articles 110-3 and 110-9 of NFPA 70, 1999 edition). Such equipment (GFCI receptacles) shall be listed or labeled and used in accordance with any instructions in the listing or labeling and shall break and restore current when the test and reset buttons are exercised.

1. The GFCI receptacle in the shower room across from nursing home room 28 was tested at 12:19 p.m. on July 23, 2013. The receptacle did not break current when tested with either the built in test buttons on the receptacle or by means of an independent testing device.

The limited use of circuit breaker protected power taps are acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip or multiple adaptor.

2. An oxygen concentrator in use by a resident in the nursing home lounge was observed at 12:47 p.m. on July 23, 2013 to be plugged into a power strip.

Based on observations made on July 23, 2013, the facility failed to assure that a corridor door was not impeded from closing and latching and was capable of being opened with less than 30 pounds of force being applied to the door. This deficiency has the potential to affect a very limited number of residents, staff and visitors in one of the two smoke compartments of the building.

The findings include:

The forces required to fully open any door manually in a means of egress shall not exceed 15 pounds of force to release the latch, 30 pounds of force to set the door in motion and 15 pounds of force to open the door to the minimum required width per section 7.2.1.4.5 of the Life Safety Code .

The corridor door to nursing home room 28 was exercised at 12:17 p.m. on July 23, 2013. Due to warping of the corridor door the door was impeded from closing easily. Once closed the door was exercised for its ability to open. Due to the warping of the door it was wedged with the frame and required over 30 pounds of force set it in motion.

Based on observations made on July 23, 2013, the facility failed to assure that doors protecting hazardous areas closed and latched with the efforts of the self-closing mechanism. This deficiency has the potential to affect more than a very limited number of residents, staff and visitors in one of the two smoke compartments of the building.

The findings include:

The 3 hour rated fire corridor door to the nursing home main soiled linen holding room was exercised at 12:55 p.m. on July 23, 2013. The self-closing mechanism on the door did not return it to a latch when closed.

Based on review of the fire drill reports at the facility on July 23, 2013, the facility failed to assure that fire drills were held at least quarterly on all shifts. This deficiency has the potential to affect all residents, patients, visitors and staff in the building.

The findings include:

The facility has three shifts, with the night shift hours being 10 p.m. to 6 a.m. in both the Nursing Home and the Critical Access Hospital. No documentation was available that a fire drill had been held during those hours for the night shift during the second quarter (April, May, June) of 2013.

Based on observations made on July 23, 2013, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies have the potential to affect more than a very limited number of residents, staff and visitors in one of the two smoke compartments of the building.

The findings include:

Equipment intended to interrupt current at fault levels (Ground-Fault Circuit-Interrupter receptacles or GFCI) shall have an interrupting rating sufficient for the nominal circuit voltage and the current available at the line terminals of the equipment (Articles 110-3 and 110-9 of NFPA 70, 1999 edition). Such equipment (GFCI receptacles) shall be listed or labeled and used in accordance with any instructions in the listing or labeling and shall break and restore current when the test and reset buttons are exercised.

1. The GFCI receptacle in the shower room across from nursing home room 28 was tested at 12:19 p.m. on July 23, 2013. The receptacle did not break current when tested with either the built in test buttons on the receptacle or by means of an independent testing device.

The limited use of circuit breaker protected power taps are acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip or multiple adaptor.

2. An oxygen concentrator in use by a resident in the nursing home lounge was observed at 12:47 p.m. on July 23, 2013 to be plugged into a power strip.