HospitalInspections.org

Based on observations and interview, the facility failed to provide doors that did not require multiple manipulations to open the doors from the inside of the room. This deficient practice could affect two of five smoke zones and residents, staff and visitors in these zones. The facility has a capacity of 14 and a census of 2 residents.

Findings Include:

Observations and interview on 10/26/11, revealed Surgery Operating Room Clean-up Room Door and the metal pull door by X-Ray had dead bolts added to them for security. The means to open these doors were by a paddle handle on the door with the dead bolt requiring a secondary manipulation to unlock and then exit the room. Maintenance Staff verified these findings during the survey process.

Based on observation and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 14 and a census of 2.

Findings include:

Observation and interview of the facility's fire drill records on 10/26/11, revealed there were no drills conducted during the night shift during the 4th quarter of 2010. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place one of five smoke compartments at risk in the event of a fire. The census was 2 with a capacity of 14.

Findings include:

Observation and staff interview on 10/26/11, the sprinkler head located in the Kitchen above the sink was corroded and had not been replaced. This observation was verified with Maintenance Staff during the survey process.

Based on observation and staff interview, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. The absence of a remote annunciator for the emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 14 certified beds and at the time of the survey the facility census was 2.

Findings include:

Observation and staff interview on 10/26/11, revealed the absence of a remote annunciator panel (storage battery powered) for the emergency generator. Maintenance Staff confirmed observations during the survey process.

Based on observation, staff interview and record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 14 with a census of 2.

Findings include:

Observation, staff interview, and record interview on 10/26/11, they could not locate the policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than four hours in a twenty-four hour period. Maintenance Staff verified this observation during the survey process.

Based on observation, staff interview and record review, the facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the fire alarm is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building in this facility with a capacity of 14 and a census of 2.

Findings include:

Observation, staff interview and record review on 10/26/11, they could not locate a written policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than four hours in a twenty-four hour period. Maintenance Staff verified this observation during the survey process.

Based on observations and interview, the facility failed to provide doors that did not require multiple manipulations to open the doors from the inside of the room. This deficient practice could affect two of five smoke zones and residents, staff and visitors in these zones. The facility has a capacity of 14 and a census of 2 residents.

Findings Include:

Observations and interview on 10/26/11, revealed Surgery Operating Room Clean-up Room Door and the metal pull door by X-Ray had dead bolts added to them for security. The means to open these doors were by a paddle handle on the door with the dead bolt requiring a secondary manipulation to unlock and then exit the room. Maintenance Staff verified these findings during the survey process.

Based on observation and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 14 and a census of 2.

Findings include:

Observation and interview of the facility's fire drill records on 10/26/11, revealed there were no drills conducted during the night shift during the 4th quarter of 2010. Maintenance Staff verified this observation during the survey process.

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by ensuring sprinkler heads are replaced when they are not free of foreign materials. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place one of five smoke compartments at risk in the event of a fire. The census was 2 with a capacity of 14.

Findings include:

Observation and staff interview on 10/26/11, the sprinkler head located in the Kitchen above the sink was corroded and had not been replaced. This observation was verified with Maintenance Staff during the survey process.

Based on observation and staff interview, the facility failed to provide a remote annunciator panel for the emergency generator in accordance with National Fire Protection Association (NFPA) Standards 99, 1999 edition. The absence of a remote annunciator for the emergency generator would affect all smoke compartments and all of the facility residents and staff. The facility has 14 certified beds and at the time of the survey the facility census was 2.

Findings include:

Observation and staff interview on 10/26/11, revealed the absence of a remote annunciator panel (storage battery powered) for the emergency generator. Maintenance Staff confirmed observations during the survey process.

Based on observation, staff interview and record review, this facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 14 with a census of 2.

Findings include:

Observation, staff interview, and record interview on 10/26/11, they could not locate the policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than four hours in a twenty-four hour period. Maintenance Staff verified this observation during the survey process.

Based on observation, staff interview and record review, the facility is not assuring that a policy is in place regarding the procedures to be taken in the event that the fire alarm is out of service for more than four hours in any twenty-four hour period. The lack of procedures could effect the actions taken by staff in the event of an emergency. This deficient practice affects all occupants of the building in this facility with a capacity of 14 and a census of 2.

Findings include:

Observation, staff interview and record review on 10/26/11, they could not locate a written policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than four hours in a twenty-four hour period. Maintenance Staff verified this observation during the survey process.