HospitalInspections.org

Based on observation, the facility failed to maintain a smoke tight ceiling. The building is composed of Type I protected construction and is required by the Life Safety Code 19.1.6.2, to maintain smoke tight ceilings if used for healthcare occupancy. This deficient could affect 10-12 staff and visitors to the facility. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).
Findings include:
Observations on 08/31/10, at 12:08 p.m., revealed the corridor leading from the Emergency Department to the X-ray department was not smoke tight. The sprinkler head on the Emergency Department side of the smoke doors had a 1/2 inch to 3/4 inch gap at the ceiling.

Administrative Staff A & Maintenance Staff verified this observation.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one (1) of fourteen (14) smoke compartments in the facility. This could affect six (6) staff members in the kitchen area. This deficient practice could affect 6-8 staff members in the kitchen area. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Observations on 08/31/10 at 11:57 a.m., revealed a gap in the ceiling of the kitchen. This deficiency was located above the sink and was 1/4 inch to 1/2 inch gap around the sprinkler head.

Administrative Staff A and Maintenance Staff A confirmed this observation.

Based on record review, the facility failed to conduct fire drills at varied times during the year 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 is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings include:

Review of the facility's fire drill records on 08/31/10, revealed that fire drills were conducted with in an hour of each other on the day shift, evening shift and night shift through out the year reviewed. The Day shift (7a-3p) were completed during the following times: 02/23/10 at 8:45 a.m., 05/26/10 at 1:00 p.m., 08/13/10 at 1:32 p.m. and 11/18/09 at 8:45 a.m. The Evening Shift (3p-11p) were completed at the following times: 03/25/10 at 4:20 p.m., 06/21/10 at 3:05 p.m., 09/14/09 at 3:30 p.m. and 12/16/09 at 5:10 p.m. The Night Shift (11p-7a) were completed at the following times: 01/17/10 at 3:15 a.m., 04/11/10 at 3:15 a.m., 07/04/10 at 3:30 a.m. and 10/25/09 at 1:45 a.m.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain 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 various numbers of staff and visitors depending on the five (5) of fourteen (14) smoke zones involved. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings include:

1.) Observations on 08/31/10, at 10:37 a.m., one (1) of eight (8) sprinkler heads located in the basement corridor outside of the Trash bin and Bio-Hazard room had dirt/lint covering the fusible link, diffuser and arms of the head. This was an upright pendent and was located above numerous utility lines. This deficiency could affect 5-6 staff members in the basement (patients, visitors are not allowed in the basement).

2.) Observations on 08/31/10, at 10:59 a.m., reveled one (1) of five (5) sprinkler heads in 4th floor Administration Corridor had dirt/lint covering the fusible link, diffuser and arm of the head. This sprinkler head was located across from the Quality Assurance Office. This deficiency could affect 10 staff members and visitors to the Administration area.

3.) Observations on 08/31/10 at 11:21 a.m., revealed one (1) of three (3) sprinkler heads located at the 3rd Floor (SNF) Nurses station was covered with dirt/ lint on the fusible link, diffuser and arms of the head. This defiance could affect 3-4 staff members and 6-10 residents and visitors to this area.

4.) Observations on 08/31/10 at 11:50 a.m., revealed one (1) of four (4) sprinkler heads located next to the Emergency Room Nurses Station. This sprinkler head had dirt/lint covering the fusible link, diffuser and arms of the head. This deficiency could affect 10-15 staff members and up to 15 patients and visitors to the Emergency Department.

5.) Observations on 08/31/10 at 11:56 a.m., revealed three (3) of eleven (11) sprinkler heads located in the kitchen had dirt/lint covering the fusible link, diffuser and arms of the heads. This deficiency could affect 6-8 staff members in the Kitchen area.

6.) Observations on 08/31/10 at 12:02 a.m., revealed one (1) of one (1) sprinkler heads located in the walk-in freezer (Kitchen storage) was coated with a yellow colored spray foam. This foam was on the glass bulb, diffuser and arms of the head. This deficiency could affect 6-8 staff members in the Kitchen area.

7.) Observations on 08/31/10 at 12:05 a.m., revealed two (2) of four (4) sprinkler heads in the Dishwashing area of the kitchen had dirt/lint covering the fusible link, diffuser and arms of the heads. This deficiency could affect 2-3 staff members in the Dishwashing area.

Administrative Staff A and Maintenance Staff A verified these observations.

Based on observations, the facility failed to maintain the clearance around gas fired mechanical devices (waterheaters, furnaces). This deficient practice can affect 2-3 staff members in one (1) of fourteen (14) smoke zones. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings Include:

Observation on 08/31/10 at 10:45 a.m., revealed that in the X-ray storage room located in the basement had vacuum cleaners and boxes stored with-in 3 feet of the water heater.

Maintenance Staff A verified this observation.

(A.)
Based on observation, the facility failed to prohibit the use of extension cords as a substitute for permanent wiring. The location of deficient practice was located in one (1) of fourteen (14) smoke compartments affecting 3-4 staff members and up to 15 patients and family in that compartment. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings include:

Observations on 08/31/10 at 11:53 a.m., reveled an orange extension cord approximately 30 feet in length being used. This extension cord was being used to power the mini refrigerator located in the Emergency Department work room.


(B.)
Based on observation, 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, placing the Staff and patients and visitors of two (2) of fourteen (14) smoke zones. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings Include:

1. Observations on 08/31/10 at 11:06 a.m., revealed an electrical outlet receptacle located on the 4th floor (Administration Corridor) Storage room across from the elevator was missing a 1/2 inch knock-out and had exposed wires. This practice could affect 10-15 staff and up to 15 patients/visitors to the facility.

2. Observations on 08/31/10 at 12:03 p.m., revealed the facility failed to maintain the electrical system in the Kitchen area. In the Kitchen walk-in cooler and freezer there was a electrical junction box located above the door of both devices missing a 1/2 inch knock-out and had exposed wires. This practice could affect 6-8 staff members in the facility.

Administrative Staff A and Maintenance Staff A verified these findings.

Based on observation, the facility failed to maintain a smoke tight ceiling. The building is composed of Type I protected construction and is required by the Life Safety Code 19.1.6.2, to maintain smoke tight ceilings if used for healthcare occupancy. This deficient could affect 10-12 staff and visitors to the facility. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).
Findings include:
Observations on 08/31/10, at 12:08 p.m., revealed the corridor leading from the Emergency Department to the X-ray department was not smoke tight. The sprinkler head on the Emergency Department side of the smoke doors had a 1/2 inch to 3/4 inch gap at the ceiling.

Administrative Staff A & Maintenance Staff verified this observation.

Based on observation, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one (1) of fourteen (14) smoke compartments in the facility. This could affect six (6) staff members in the kitchen area. This deficient practice could affect 6-8 staff members in the kitchen area. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Observations on 08/31/10 at 11:57 a.m., revealed a gap in the ceiling of the kitchen. This deficiency was located above the sink and was 1/4 inch to 1/2 inch gap around the sprinkler head.

Administrative Staff A and Maintenance Staff A confirmed this observation.

Based on record review, the facility failed to conduct fire drills at varied times during the year 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 is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings include:

Review of the facility's fire drill records on 08/31/10, revealed that fire drills were conducted with in an hour of each other on the day shift, evening shift and night shift through out the year reviewed. The Day shift (7a-3p) were completed during the following times: 02/23/10 at 8:45 a.m., 05/26/10 at 1:00 p.m., 08/13/10 at 1:32 p.m. and 11/18/09 at 8:45 a.m. The Evening Shift (3p-11p) were completed at the following times: 03/25/10 at 4:20 p.m., 06/21/10 at 3:05 p.m., 09/14/09 at 3:30 p.m. and 12/16/09 at 5:10 p.m. The Night Shift (11p-7a) were completed at the following times: 01/17/10 at 3:15 a.m., 04/11/10 at 3:15 a.m., 07/04/10 at 3:30 a.m. and 10/25/09 at 1:45 a.m.

Maintenance Staff A verified these observations.

Based on observation, the facility failed to maintain 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 various numbers of staff and visitors depending on the five (5) of fourteen (14) smoke zones involved. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings include:

1.) Observations on 08/31/10, at 10:37 a.m., one (1) of eight (8) sprinkler heads located in the basement corridor outside of the Trash bin and Bio-Hazard room had dirt/lint covering the fusible link, diffuser and arms of the head. This was an upright pendent and was located above numerous utility lines. This deficiency could affect 5-6 staff members in the basement (patients, visitors are not allowed in the basement).

2.) Observations on 08/31/10, at 10:59 a.m., reveled one (1) of five (5) sprinkler heads in 4th floor Administration Corridor had dirt/lint covering the fusible link, diffuser and arm of the head. This sprinkler head was located across from the Quality Assurance Office. This deficiency could affect 10 staff members and visitors to the Administration area.

3.) Observations on 08/31/10 at 11:21 a.m., revealed one (1) of three (3) sprinkler heads located at the 3rd Floor (SNF) Nurses station was covered with dirt/ lint on the fusible link, diffuser and arms of the head. This defiance could affect 3-4 staff members and 6-10 residents and visitors to this area.

4.) Observations on 08/31/10 at 11:50 a.m., revealed one (1) of four (4) sprinkler heads located next to the Emergency Room Nurses Station. This sprinkler head had dirt/lint covering the fusible link, diffuser and arms of the head. This deficiency could affect 10-15 staff members and up to 15 patients and visitors to the Emergency Department.

5.) Observations on 08/31/10 at 11:56 a.m., revealed three (3) of eleven (11) sprinkler heads located in the kitchen had dirt/lint covering the fusible link, diffuser and arms of the heads. This deficiency could affect 6-8 staff members in the Kitchen area.

6.) Observations on 08/31/10 at 12:02 a.m., revealed one (1) of one (1) sprinkler heads located in the walk-in freezer (Kitchen storage) was coated with a yellow colored spray foam. This foam was on the glass bulb, diffuser and arms of the head. This deficiency could affect 6-8 staff members in the Kitchen area.

7.) Observations on 08/31/10 at 12:05 a.m., revealed two (2) of four (4) sprinkler heads in the Dishwashing area of the kitchen had dirt/lint covering the fusible link, diffuser and arms of the heads. This deficiency could affect 2-3 staff members in the Dishwashing area.

Administrative Staff A and Maintenance Staff A verified these observations.

Based on observations, the facility failed to maintain the clearance around gas fired mechanical devices (waterheaters, furnaces). This deficient practice can affect 2-3 staff members in one (1) of fourteen (14) smoke zones. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings Include:

Observation on 08/31/10 at 10:45 a.m., revealed that in the X-ray storage room located in the basement had vacuum cleaners and boxes stored with-in 3 feet of the water heater.

Maintenance Staff A verified this observation.

(A.)
Based on observation, the facility failed to prohibit the use of extension cords as a substitute for permanent wiring. The location of deficient practice was located in one (1) of fourteen (14) smoke compartments affecting 3-4 staff members and up to 15 patients and family in that compartment. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings include:

Observations on 08/31/10 at 11:53 a.m., reveled an orange extension cord approximately 30 feet in length being used. This extension cord was being used to power the mini refrigerator located in the Emergency Department work room.


(B.)
Based on observation, 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, placing the Staff and patients and visitors of two (2) of fourteen (14) smoke zones. This facility is licensed for a total of 64 (39 skilled, 25 acute) and a census of 34 (32 skilled, 2 acute).

Findings Include:

1. Observations on 08/31/10 at 11:06 a.m., revealed an electrical outlet receptacle located on the 4th floor (Administration Corridor) Storage room across from the elevator was missing a 1/2 inch knock-out and had exposed wires. This practice could affect 10-15 staff and up to 15 patients/visitors to the facility.

2. Observations on 08/31/10 at 12:03 p.m., revealed the facility failed to maintain the electrical system in the Kitchen area. In the Kitchen walk-in cooler and freezer there was a electrical junction box located above the door of both devices missing a 1/2 inch knock-out and had exposed wires. This practice could affect 6-8 staff members in the facility.

Administrative Staff A and Maintenance Staff A verified these findings.