HospitalInspections.org

Based on observations, the facility failed to maintain a Type II (III) construction type in one location of the facility by allowing a penetration in the ceiling to be present. This deficient practice could affect approximately 12 staff members only due to the fact that this occurred in a non-patient area (basement). The facility had a capacity of 25 residents and a census of 9.

Findings include:

Observations on 1-28-11 revealed a sprinkler pipe penetration (approximately 3/4 inch in size) located in the ceiling of Conference Room B in the Basement.

The Administrator confirmed this finding.

Based on observations, the facility failed to maintain the doors to one room in proper working order. This would affect approximately 7 staff members only due to the fact that this occurred within a non-patient area (Administration). The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11, revealed the presence of a "kick down" hold open device on the bottom of the door to the David Miller Board Room.

The Administrator confirmed this finding.

Based on observations, the facility failed to properly maintain one exit stairwell by allowing penetrations to be present. This would effect approximately 5 patients and 3 staff members within the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed a hole (approximately 1 1/2 inch in size) located in the ceiling tile in the south stairwell the leads to the Physical Therapy area.

The Administrator confirmed this finding.

Based on observations, the facility failed to maintain 1 Smoke Barrier free of penetrations. This affects 2 smoke zones, affecting approximately 6 patients and 14 staff members. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed a center of conduit penetration (approximately 1 inch in size) located above the suspended ceiling, in the smoke barrier that is located near the Courtyard Exit.

The Administrator confirmed this finding.

A.
Based on observations, the facility failed to maintain 2 hazardous rooms properly separated by failing to properly maintain the doors to the 2 rooms. This affects approximately 6 staff members only due to the fact that the deficiency occurred in a non-patient area (basement). The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed the following:

1. The door to the Laundry Room in the Basement failed to close and latch properly into the door frame when tested.

2. The door to Central Storage #2 failed to close and latch properly into the door frame when tested.

The Administrator confirmed these findings.

B.
Based on observations, the facility failed to maintain 1 hazardous room properly separated by allowing penetrations to be present. This affects approximately 2 staff members only due to the fact that the deficiency occurred in a non-patient area (basement). The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed a conduit penetration (approximately 1 inch in size) located above the the generator box in Central Storage #2.

The Administrator confirmed this finding.

A.
Based on observations, the facility failed to provide or maintain 3 emergency light units in proper working order. This affects approximately 3 patients and 9 staff members. The facility had a license of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed the following:

1. The buildings generator area revealed the absence of an emergency light unit with battery back up capabilities.

2. The emergency light unit near the Operating Room Nurses Station failed to illuminate on battery back up power when tested.

3. The Operating Room failed to be equipped with an emergency light unit.

The Administrator confirmed these findings.

B.
Based on observations, the facility failed to properly document the required testing of the buildings emergency light units. This affects approximately 3 patients and 9 staff members. The facility had a license of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed the facility failed to provide documentation of a 30 second monthly test and a 90 minute annual test of the buildings emergency light units.

The Administrator confirmed this finding.

Based on record review, the facility failed to comply with the fire drill requirements by failing to conduct and document quarterly fire drills on each nursing shift. This would affect all occupants and staff at the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Record review on 1-28-11 revealed the facility failed to document quarterly fire drills on each nursing shift. The only documented fire drills within the previous 12 months that the facility provided were dated 1-11-11 at 1600 hours and 10-28-10 at 1300 hours.

The Administrator confirmed this finding.

A.
Based on observations, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by failing to document the required sensitivity test of the buildings smoke detectors. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the absence of a documented sensitivity test of the buildings smoke detectors.

The Administrator confirmed this finding.

B.
Based on observations, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by failing to manually lock the electrical breaker that is dedicated to the facilities fire alarm system. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the absence of a manual locking device on the electrical breaker that is dedicated to the buildings fire alarm system. This breaker shall be locked in the "On" position to prevent accidental disconnection

The Administrator confirmed this finding.

Based on observations, the facility failed to provide or maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition by failing to provide sprinkler coverage to all required areas. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the following:

1. The walk-in freezer failed to be protected by an approved automatic sprinkler system.

2. The overhead door located in the garage failed to have sprinkler coverage underneath the door.

The Administrator confirmed these findings.

A.
Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to provide the required documentation of quarterly inspections of the buildings automatic sprinkler system. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the facility failed to document and conduct quarterly inspections of the buildings automatic sprinkler system. The only documentation that the facility could provide was one inspection dated 5-13-10.

The Administrator confirmed this finding.

B.
Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by mixing sprinkler heads types in the same area. This affects 2 patients and 3 staff members. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the Radiology internal hallway was protected by a mixture of sprinkler head types. This area contained 4 Fusible Link and 2 Quick Response sprinkler heads

The Administrator confirmed this finding.

Based on observations, the facility failed to properly maintain the storage of compressed medical gases in accordance with Section 4.3.1.1.2, NFPA 99, Health Care Facilities, 1999 edition. This affects approximately 3 patients and 5 staff members. The facility had a license of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed 1 oxygen bottle that was not properly secured in the storage room near the Nurse's Station in the S.C.U.

The Administrator confirmed this finding.

Based on observations, the facility failed to have Alcohol Based Hand Rub dispensers properly located. This affects approximately 6 patients and 9 staff members. The facility has a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11, revealed Alcohol Based Hand Rub dispensers located above an electrical source in the following areas:

1) Room LDR #2
2) X-Ray entrance from the Department Area
3) Near Trauma #1

The Administrator confirmed these findings.

A.
Based on observations, 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 by allowing unapproved electrical items to be plugged into a surge protector. This affects approximately 2 staff members only due to the fact that this occurred in a non-patient area (Basement). The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11, revealed a washing machine plugged into a surge protector located in the Laundry Room in the Basement.

The Administrator confirmed this finding.

B.
Based on observations, 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 by failing to cover an electrical junction box . This affects approximately 3 staff members only due to the fact that this occurred in a non-patient area (Basement). The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11, revealed an uncovered electrical junction box, located in Boiler Room #1 in the Basement.

The Administrator confirmed this finding.

Based on observations, the facility failed to comply with the requirements for set forth in the Life Safety Code, 2000 Edition, in reference to having a written policy on how to handle a situation in which the building would lose the water supply to the automatic sprinkler system (Fire Watch).

Findings include:

Observations on 1-28-11 revealed the facility did provide documentation of a written policy that would come into effect if the building were to lose its water source to its sprinkler system (Fire Watch).

The Administrator confirmed this finding.

Based on observations, the facility failed to comply with the requirements for set forth in the Life Safety Code, 2000 Edition, in reference to having a written policy on how to handle a situation in which the building would lose the power to it's fire alarm system. (Fire Watch).

Findings include:

Observations on 1-28-11 revealed the facility did provide documentation of a written policy that would come into effect if the building were to lose the power to it's fire alarm system (Fire Watch).

The Administrator confirmed this finding.

Based on observations, the facility failed to maintain a Type II (III) construction type in one location of the facility by allowing a penetration in the ceiling to be present. This deficient practice could affect approximately 12 staff members only due to the fact that this occurred in a non-patient area (basement). The facility had a capacity of 25 residents and a census of 9.

Findings include:

Observations on 1-28-11 revealed a sprinkler pipe penetration (approximately 3/4 inch in size) located in the ceiling of Conference Room B in the Basement.

The Administrator confirmed this finding.

Based on observations, the facility failed to maintain the doors to one room in proper working order. This would affect approximately 7 staff members only due to the fact that this occurred within a non-patient area (Administration). The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11, revealed the presence of a "kick down" hold open device on the bottom of the door to the David Miller Board Room.

The Administrator confirmed this finding.

Based on observations, the facility failed to properly maintain one exit stairwell by allowing penetrations to be present. This would effect approximately 5 patients and 3 staff members within the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed a hole (approximately 1 1/2 inch in size) located in the ceiling tile in the south stairwell the leads to the Physical Therapy area.

The Administrator confirmed this finding.

Based on observations, the facility failed to maintain 1 Smoke Barrier free of penetrations. This affects 2 smoke zones, affecting approximately 6 patients and 14 staff members. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed a center of conduit penetration (approximately 1 inch in size) located above the suspended ceiling, in the smoke barrier that is located near the Courtyard Exit.

The Administrator confirmed this finding.

A.
Based on observations, the facility failed to maintain 2 hazardous rooms properly separated by failing to properly maintain the doors to the 2 rooms. This affects approximately 6 staff members only due to the fact that the deficiency occurred in a non-patient area (basement). The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed the following:

1. The door to the Laundry Room in the Basement failed to close and latch properly into the door frame when tested.

2. The door to Central Storage #2 failed to close and latch properly into the door frame when tested.

The Administrator confirmed these findings.

B.
Based on observations, the facility failed to maintain 1 hazardous room properly separated by allowing penetrations to be present. This affects approximately 2 staff members only due to the fact that the deficiency occurred in a non-patient area (basement). The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed a conduit penetration (approximately 1 inch in size) located above the the generator box in Central Storage #2.

The Administrator confirmed this finding.

A.
Based on observations, the facility failed to provide or maintain 3 emergency light units in proper working order. This affects approximately 3 patients and 9 staff members. The facility had a license of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed the following:

1. The buildings generator area revealed the absence of an emergency light unit with battery back up capabilities.

2. The emergency light unit near the Operating Room Nurses Station failed to illuminate on battery back up power when tested.

3. The Operating Room failed to be equipped with an emergency light unit.

The Administrator confirmed these findings.

B.
Based on observations, the facility failed to properly document the required testing of the buildings emergency light units. This affects approximately 3 patients and 9 staff members. The facility had a license of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11 revealed the facility failed to provide documentation of a 30 second monthly test and a 90 minute annual test of the buildings emergency light units.

The Administrator confirmed this finding.

Based on record review, the facility failed to comply with the fire drill requirements by failing to conduct and document quarterly fire drills on each nursing shift. This would affect all occupants and staff at the facility. The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Record review on 1-28-11 revealed the facility failed to document quarterly fire drills on each nursing shift. The only documented fire drills within the previous 12 months that the facility provided were dated 1-11-11 at 1600 hours and 10-28-10 at 1300 hours.

The Administrator confirmed this finding.

A.
Based on observations, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by failing to document the required sensitivity test of the buildings smoke detectors. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the absence of a documented sensitivity test of the buildings smoke detectors.

The Administrator confirmed this finding.

B.
Based on observations, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by failing to manually lock the electrical breaker that is dedicated to the facilities fire alarm system. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the absence of a manual locking device on the electrical breaker that is dedicated to the buildings fire alarm system. This breaker shall be locked in the "On" position to prevent accidental disconnection

The Administrator confirmed this finding.

Based on observations, the facility failed to provide or maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition by failing to provide sprinkler coverage to all required areas. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the following:

1. The walk-in freezer failed to be protected by an approved automatic sprinkler system.

2. The overhead door located in the garage failed to have sprinkler coverage underneath the door.

The Administrator confirmed these findings.

A.
Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to provide the required documentation of quarterly inspections of the buildings automatic sprinkler system. This affects all patients and staff at the facility. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the facility failed to document and conduct quarterly inspections of the buildings automatic sprinkler system. The only documentation that the facility could provide was one inspection dated 5-13-10.

The Administrator confirmed this finding.

B.
Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by mixing sprinkler heads types in the same area. This affects 2 patients and 3 staff members. The facility had a capacity of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed the Radiology internal hallway was protected by a mixture of sprinkler head types. This area contained 4 Fusible Link and 2 Quick Response sprinkler heads

The Administrator confirmed this finding.

Based on observations, the facility failed to properly maintain the storage of compressed medical gases in accordance with Section 4.3.1.1.2, NFPA 99, Health Care Facilities, 1999 edition. This affects approximately 3 patients and 5 staff members. The facility had a license of 25 residents and a census of 9 residents.

Findings include:

Observations on 1-28-11 revealed 1 oxygen bottle that was not properly secured in the storage room near the Nurse's Station in the S.C.U.

The Administrator confirmed this finding.

Based on observations, the facility failed to have Alcohol Based Hand Rub dispensers properly located. This affects approximately 6 patients and 9 staff members. The facility has a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11, revealed Alcohol Based Hand Rub dispensers located above an electrical source in the following areas:

1) Room LDR #2
2) X-Ray entrance from the Department Area
3) Near Trauma #1

The Administrator confirmed these findings.

A.
Based on observations, 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 by allowing unapproved electrical items to be plugged into a surge protector. This affects approximately 2 staff members only due to the fact that this occurred in a non-patient area (Basement). The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11, revealed a washing machine plugged into a surge protector located in the Laundry Room in the Basement.

The Administrator confirmed this finding.

B.
Based on observations, 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 by failing to cover an electrical junction box . This affects approximately 3 staff members only due to the fact that this occurred in a non-patient area (Basement). The facility had a capacity of 25 patients and a census of 9 patients.

Findings include:

Observations on 1-28-11, revealed an uncovered electrical junction box, located in Boiler Room #1 in the Basement.

The Administrator confirmed this finding.

Based on observations, the facility failed to comply with the requirements for set forth in the Life Safety Code, 2000 Edition, in reference to having a written policy on how to handle a situation in which the building would lose the water supply to the automatic sprinkler system (Fire Watch).

Findings include:

Observations on 1-28-11 revealed the facility did provide documentation of a written policy that would come into effect if the building were to lose its water source to its sprinkler system (Fire Watch).

The Administrator confirmed this finding.

Based on observations, the facility failed to comply with the requirements for set forth in the Life Safety Code, 2000 Edition, in reference to having a written policy on how to handle a situation in which the building would lose the power to it's fire alarm system. (Fire Watch).

Findings include:

Observations on 1-28-11 revealed the facility did provide documentation of a written policy that would come into effect if the building were to lose the power to it's fire alarm system (Fire Watch).

The Administrator confirmed this finding.