HospitalInspections.org

Based on observations and staff interview, this facility is not providing firewalls with a two-hour fire rating as required. This deficient practice affects all occupants including staff, visitors and patients. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 11/18/15, between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. The Fire Door in the Corridor by the Kitchen did not close and latch properly when tested. This door is part of a 2 hour rated fire wall.
2. There was a penetration, (approximately 4 inches by 4 inches), around conduit extending through the 2 hour wall near Room 127.
3. There was an open pipe that was not sealed, extending through the 2 hour wall near Room 127.
4. There was a gap, (approximately 3/16 inch), in the drywall of the 2 hour wall to the Wound Healing Clinic.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, it was determined the facility was a one-story building and consisted of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with fire rated materials. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 11/18/15, between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. There was a hole, (approximately 4 inches in diameter), in a ceiling tile in the Lift Storage Closet by Room 139.
2. There was a penetration, (approximately 1 inches by 5 inches), around 5 pipes extending through the Fire Alarm Panel Room.
3. There was a hole, (approximately 4 inches in diameter), in a ceiling tile in Exam Room 2 of the Emergency Room.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 11/18/15, between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. The corridor door near the entry to Counseling Services did not close and latch properly when tested.
2. The corridor door near the entry to Counseling Services had 6 holes in the door. 2 of the holes were approximately 1/4 inch and the other 2 holes were approximately 3/16 inch in size.
3. The door to the Small Storage Room by Room 127 did not close and latch properly when tested.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 11/18/15 at 9:59 a.m., revealed the following deficiencies:

1. There was no available documentation of an annual 90 minute testing of the emergency lighting system.
2. There was no available documentation of monthly testing of the emergency lighting system for the months of July and September of 2014.
3. Available documentation of testing of the emergency lighting system from 10/31/13 to 8/29/14 did not indicate that each individual lighting unit was marked as tested.

Maintenance Staff A verified record review during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills under varied conditions at different times of the day as required. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 11/18/15 at 10:54 a.m., revealed the following deficiencies:

1. There was no available documentation of a fire drill conducted for the 1st Shift in the 4th Quarter of 2014.
2. The facility failed to hold fire drills under varied conditions at different times of the day as required. The 2014 fire drills were conducted on the 1st Shift as follows: 2/26/14 at 9:00 a.m. 6/25/14 at 9:00 a.m. 7/31/14 at 10:00 a.m. 8/5/14 at 10:10 a.m. The 2014 fire drills were conducted on the 2nd Shift as follows: 1/23/14 at 6:30 p.m. 2/26/14 at 6:30 p.m. 4/14/14 at 6:30 p.m. 12/29/14 at 6:48 p.m. The 2015 fire drills were conducted on the 2nd Shift as follows: 3/30/15 at 8:05 p.m. 8/13/15 at 8:05 p.m. 6/26/15 at 8:45 p.m. 7/30/15 at 8:30 p.m.

Maintenance Staff A verified record review during the survey process.

Based on record review, observation and staff interview, the facility failed to provide a properly maintained fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, the National Fire Alarm Code, 1999 edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review, observation and staff interview on 11/18/15, between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. There was no available documentation of a 2nd semi annual inspection of the fire alarm system for 2015. The last available documentation of a fire alarm inspection was dated 2/17/15. There was no documentation of a fire alarm inspection six months after that date as required.
2. The facility failed to provide a fire alarm notification device for the enclosed courtyard. Occupants in this area would have to enter the building in the event of an emergency.
3. The last available documentation of smoke detector sensitivity testing was dated 2/9/11. The fire alarm system is addressable, however the facility did not have documentation of sensitivity testing for every two years as required.

Maintenance Staff A verified record review and observations during the survey process.

Based on record review, observations and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review, observations and staff interview on 11/18/15 between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. There was no available documentation of a sprinkler system inspection for the 2nd Quarter of 2015.
2. There was paint on the fusible link of a sprinkler head by the entry to Counseling Services.
3. There were missing escutcheons for sprinkler heads in the following locations: Physical Therapy Room, (3 missing). Cafeteria. Kitchen, (4 missing). Corridor by the Fire Door near the Kitchen. Room 120. Shower Room by Room 129. Supply Closet by Room 138. ICN Corridor. Corridor outside Surgery Waiting Room. By the doors to the Specialty Clinic. By the doors to the Medical Clinic. Medical Clinic Lobby.

Maintenance Staff A verified record review and observations during the survey process.

(A)
Based on observation and staff interview, the facility failed to provide a remote manual stop station for the emergency generator set as required by National Fire Protection Association, NFPA 110, 1999 edition 3-5.5.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 6 patients.

Findings include,

Observation and staff interview on 11/18/15 at 11:22 a.m., revealed the facility failed to provide a remote manual stop station for the emergency generator set, located outside of the room containing the generator. Maintenance Staff A verified observations during the survey process.

NFPA 110, 1999 edition 3-5.5.6

3-5.5.6* All level 1 and level 2 installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building

A3-5.5.6 For level 1 and level 2 systems located outdoors the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.


(B)
Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and patients. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 11/18/15 at 9:55 a.m., revealed a gap in the weekly generator inspection log between 7/13/15 and 7/27/15. During this time a weekly inspection was not conducted. Maintenance Staff A verified record review during the survey process.

Based on observation and staff 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, 1999 edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observation and staff interview on 11/18/15 at 11:38 a.m., revealed an open electrical junction box in the Laundry Room. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility is not providing firewalls with a two-hour fire rating as required. This deficient practice affects all occupants including staff, visitors and patients. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 11/18/15, between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. The Fire Door in the Corridor by the Kitchen did not close and latch properly when tested. This door is part of a 2 hour rated fire wall.
2. There was a penetration, (approximately 4 inches by 4 inches), around conduit extending through the 2 hour wall near Room 127.
3. There was an open pipe that was not sealed, extending through the 2 hour wall near Room 127.
4. There was a gap, (approximately 3/16 inch), in the drywall of the 2 hour wall to the Wound Healing Clinic.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, it was determined the facility was a one-story building and consisted of protected non-combustible construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with fire rated materials. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 11/18/15, between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. There was a hole, (approximately 4 inches in diameter), in a ceiling tile in the Lift Storage Closet by Room 139.
2. There was a penetration, (approximately 1 inches by 5 inches), around 5 pipes extending through the Fire Alarm Panel Room.
3. There was a hole, (approximately 4 inches in diameter), in a ceiling tile in Exam Room 2 of the Emergency Room.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility is not ensuring that doors to rooms are provided with suitable hardware that keep the doors shut tightly into their frames. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 11/18/15, between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. The corridor door near the entry to Counseling Services did not close and latch properly when tested.
2. The corridor door near the entry to Counseling Services had 6 holes in the door. 2 of the holes were approximately 1/4 inch and the other 2 holes were approximately 3/16 inch in size.
3. The door to the Small Storage Room by Room 127 did not close and latch properly when tested.

Maintenance Staff A verified observations during the survey process.

Based on record review and staff interview, the facility failed to properly test the emergency egress lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 11/18/15 at 9:59 a.m., revealed the following deficiencies:

1. There was no available documentation of an annual 90 minute testing of the emergency lighting system.
2. There was no available documentation of monthly testing of the emergency lighting system for the months of July and September of 2014.
3. Available documentation of testing of the emergency lighting system from 10/31/13 to 8/29/14 did not indicate that each individual lighting unit was marked as tested.

Maintenance Staff A verified record review during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills under varied conditions at different times of the day as required. Fire drills shall be held at unexpected times under varying conditions, at least quarterly on each shift. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 11/18/15 at 10:54 a.m., revealed the following deficiencies:

1. There was no available documentation of a fire drill conducted for the 1st Shift in the 4th Quarter of 2014.
2. The facility failed to hold fire drills under varied conditions at different times of the day as required. The 2014 fire drills were conducted on the 1st Shift as follows: 2/26/14 at 9:00 a.m. 6/25/14 at 9:00 a.m. 7/31/14 at 10:00 a.m. 8/5/14 at 10:10 a.m. The 2014 fire drills were conducted on the 2nd Shift as follows: 1/23/14 at 6:30 p.m. 2/26/14 at 6:30 p.m. 4/14/14 at 6:30 p.m. 12/29/14 at 6:48 p.m. The 2015 fire drills were conducted on the 2nd Shift as follows: 3/30/15 at 8:05 p.m. 8/13/15 at 8:05 p.m. 6/26/15 at 8:45 p.m. 7/30/15 at 8:30 p.m.

Maintenance Staff A verified record review during the survey process.

Based on record review, observation and staff interview, the facility failed to provide a properly maintained fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, the National Fire Alarm Code, 1999 edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review, observation and staff interview on 11/18/15, between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. There was no available documentation of a 2nd semi annual inspection of the fire alarm system for 2015. The last available documentation of a fire alarm inspection was dated 2/17/15. There was no documentation of a fire alarm inspection six months after that date as required.
2. The facility failed to provide a fire alarm notification device for the enclosed courtyard. Occupants in this area would have to enter the building in the event of an emergency.
3. The last available documentation of smoke detector sensitivity testing was dated 2/9/11. The fire alarm system is addressable, however the facility did not have documentation of sensitivity testing for every two years as required.

Maintenance Staff A verified record review and observations during the survey process.

Based on record review, observations and staff interview, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, 1998 edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review, observations and staff interview on 11/18/15 between 9:00 a.m. and 1:00 p.m., revealed the following deficiencies:

1. There was no available documentation of a sprinkler system inspection for the 2nd Quarter of 2015.
2. There was paint on the fusible link of a sprinkler head by the entry to Counseling Services.
3. There were missing escutcheons for sprinkler heads in the following locations: Physical Therapy Room, (3 missing). Cafeteria. Kitchen, (4 missing). Corridor by the Fire Door near the Kitchen. Room 120. Shower Room by Room 129. Supply Closet by Room 138. ICN Corridor. Corridor outside Surgery Waiting Room. By the doors to the Specialty Clinic. By the doors to the Medical Clinic. Medical Clinic Lobby.

Maintenance Staff A verified record review and observations during the survey process.

(A)
Based on observation and staff interview, the facility failed to provide a remote manual stop station for the emergency generator set as required by National Fire Protection Association, NFPA 110, 1999 edition 3-5.5.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 6 patients.

Findings include,

Observation and staff interview on 11/18/15 at 11:22 a.m., revealed the facility failed to provide a remote manual stop station for the emergency generator set, located outside of the room containing the generator. Maintenance Staff A verified observations during the survey process.

NFPA 110, 1999 edition 3-5.5.6

3-5.5.6* All level 1 and level 2 installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building

A3-5.5.6 For level 1 and level 2 systems located outdoors the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.


(B)
Based on record review and staff interview, the facility failed to maintain and test the emergency generator power supply as required. Emergency generators are required to be inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with National Fire Protection Association (NFPA), Standard 99, 3.4.4.1, and NFPA 110, 8.4.2. The emergency generator would effect all smoke compartments and all facility staff and patients. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 11/18/15 at 9:55 a.m., revealed a gap in the weekly generator inspection log between 7/13/15 and 7/27/15. During this time a weekly inspection was not conducted. Maintenance Staff A verified record review during the survey process.

Based on observation and staff 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, 1999 edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observation and staff interview on 11/18/15 at 11:38 a.m., revealed an open electrical junction box in the Laundry Room. Maintenance Staff A verified observations during the survey process.