HospitalInspections.org

K-11
Based on observation and interview, the facility failed to provide 2-hour fire rated construction separation, failed to maintain the construction type of the facility by having non-fire treated wood installed in the facility. This deficient practice affected all patients, staff and visitors in both buildings. The facility capacity is 25 and the census was 1.
Findings include:
Observation on 1-10-12 at 10:15 a.m. revealed an unsealed conduit, data wire and sprinkler pipe penetration; above the double door near the Emergency room by exam room 13. Observation confirmed by maintenance staff.
Observation on 1-10-12 at 10:20 a.m. of the south vestibule near the Acute care revealed above the west and east doors an unsealed conduit and data wire penetration and a unsealed sprinkler pipe penetration. There were also holes in the smoke separation walls. Observation confirmed by maintenance staff.

Observation on 1-10-12 at 10:40 a.m. above the double separation doors near the gift shop revealed unsealed conduit and data wire penetrations. Observation confirmed by maintenance staff.
NFPA Standard:
Additions shall be separated from any existing structure not conforming to the provisions with Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. 2000 NFPA 101, 19.1.1.4

K-38
Based on observation and interview the facility failed to maintain the means of egress free from impediments. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 25 and the census was 1.
Findings Include:
Observation on 1-10-12 at 11:30 revealed the Northwest exiting corridor from the acute care unit was being used to store wheel chairs, patient scales, chairs causing the exiting corridor to be obstructed. Observation confirmed by maintenance staff.
NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

K-47
Based on observation and interview, the facility failed to provide exit to indicate the continuous path of egress in the acute care area. The facility capacity is 25 and the census was 1.
Findings include:
Observation on 1-10-12 at 11:15 a.m. revealed the facility failed to provide exit signage marking the means of egress in the acute care area. Observation confirmed by maintenance staff at the time of the inspection.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 7.10.2

K-51
Based on staff interview and record review, the facility did not assure that the fire alarm system is in accordance with NFPA 72 and chapter 9.6.4 of NFPA 101 by ensuring that an approved central station appropriately and continuously monitors the fire alarm and summons an organized fire department upon receipt of a fire alarm transmission. This deficient practice affects all occupants of the building. The facility census is 1 with a capacity of 25. Findings include:
Observation on 1-10-12 at 11:45 a.m. the facility failed to provide information and/or documentation assuring the facility ' s fire alarm signal is continuously monitored by a central reporting station. Observation confirmed by maintenance staff.
NFPA Standard: If the remote supervising station is at a location other than the public fire service communications center, alarm signals shall be immediately retransmitted to the public fire service communications center. 1999 NFPA 72, 5-4.6.1

K-69
Based on observation, record review and staff interview, the facility failed to protect cooking facilities in accordance with NFPA 96 and UL 300 Standards. This practice affected all patients, visitors and staff that use the facility. Facility census was 1 and has a capacity of 25.
Findings include:
Observation on 1-10-12 at 11:25 a.m. of the facility kitchen revealed the facility ' s kitchen hood system was constructed of glass side and the top was ceiling tile and exhaust vents in the middle. The kitchen hood does not meet the requirements of NFPA 96 and UL300 Standards. Observation confirmed by maintenance staff.
NFPA 96 Standard: 5.1.1 The hood or that portion of a primary collection means designed for collecting cooking vapors and residues shall be constructed of and be supported by steel not less than 1.09 mm (0.043 in.) (No. 18 MSG) in thickness, stainless steel not less than 0.94 mm (0.037 in.) (No. 20 MSG) in thickness, or other approved material of equivalent strength and fire and corrosion resistance.
5.1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood ' s lower outermost perimeter.
5.1.3 Seams, joints, and penetrations of the hood shall be permitted to be internally welded, provided that the weld is formed smooth or ground smooth, so as to not trap grease, and is cleanable.
5.1.4* Internal hood joints, seams, filter support frames, and appurtenances attached inside the hood shall be sealed or otherwise made greasetight.

K-147
Based on observation and interview the facility failed to maintain the electrical system in accordance with NFPA 70, 1999ed. by having open electrical boxes, by having panels that are not dead front, by having non-metallic sheathed cable installed and by having unused openings in boxes. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 25 and the census was 1.
Findings Include:
Observation on 1-10-12 at 10:30 a.m. reveal a junction box above the ceiling in the south vestibule near the acute care are did not have an approved cover installed. Observation confirmed by maintenance staff.
Observation on 1-10-12 at 11:00 a.m. of the mechanical room in the Physical Therapy area revealed the electrical panel did not have the approved cover installed. Observation confirmed by maintenance staff.
Observation on 1-10-12 at 11:15 a.m. of the boiler room revealed a junction box near the west wall and conduit elbow near the south door did not have approved covers installed. Observation confirmed by maintenance staff.

K-11
Based on observation and interview, the facility failed to provide 2-hour fire rated construction separation, failed to maintain the construction type of the facility by having non-fire treated wood installed in the facility. This deficient practice affected all patients, staff and visitors in both buildings. The facility capacity is 25 and the census was 1.
Findings include:
Observation on 1-10-12 at 10:15 a.m. revealed an unsealed conduit, data wire and sprinkler pipe penetration; above the double door near the Emergency room by exam room 13. Observation confirmed by maintenance staff.
Observation on 1-10-12 at 10:20 a.m. of the south vestibule near the Acute care revealed above the west and east doors an unsealed conduit and data wire penetration and a unsealed sprinkler pipe penetration. There were also holes in the smoke separation walls. Observation confirmed by maintenance staff.

Observation on 1-10-12 at 10:40 a.m. above the double separation doors near the gift shop revealed unsealed conduit and data wire penetrations. Observation confirmed by maintenance staff.
NFPA Standard:
Additions shall be separated from any existing structure not conforming to the provisions with Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. 2000 NFPA 101, 19.1.1.4

K-38
Based on observation and interview the facility failed to maintain the means of egress free from impediments. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 25 and the census was 1.
Findings Include:
Observation on 1-10-12 at 11:30 revealed the Northwest exiting corridor from the acute care unit was being used to store wheel chairs, patient scales, chairs causing the exiting corridor to be obstructed. Observation confirmed by maintenance staff.
NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

K-47
Based on observation and interview, the facility failed to provide exit to indicate the continuous path of egress in the acute care area. The facility capacity is 25 and the census was 1.
Findings include:
Observation on 1-10-12 at 11:15 a.m. revealed the facility failed to provide exit signage marking the means of egress in the acute care area. Observation confirmed by maintenance staff at the time of the inspection.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 7.10.2

K-51
Based on staff interview and record review, the facility did not assure that the fire alarm system is in accordance with NFPA 72 and chapter 9.6.4 of NFPA 101 by ensuring that an approved central station appropriately and continuously monitors the fire alarm and summons an organized fire department upon receipt of a fire alarm transmission. This deficient practice affects all occupants of the building. The facility census is 1 with a capacity of 25. Findings include:
Observation on 1-10-12 at 11:45 a.m. the facility failed to provide information and/or documentation assuring the facility ' s fire alarm signal is continuously monitored by a central reporting station. Observation confirmed by maintenance staff.
NFPA Standard: If the remote supervising station is at a location other than the public fire service communications center, alarm signals shall be immediately retransmitted to the public fire service communications center. 1999 NFPA 72, 5-4.6.1

K-69
Based on observation, record review and staff interview, the facility failed to protect cooking facilities in accordance with NFPA 96 and UL 300 Standards. This practice affected all patients, visitors and staff that use the facility. Facility census was 1 and has a capacity of 25.
Findings include:
Observation on 1-10-12 at 11:25 a.m. of the facility kitchen revealed the facility ' s kitchen hood system was constructed of glass side and the top was ceiling tile and exhaust vents in the middle. The kitchen hood does not meet the requirements of NFPA 96 and UL300 Standards. Observation confirmed by maintenance staff.
NFPA 96 Standard: 5.1.1 The hood or that portion of a primary collection means designed for collecting cooking vapors and residues shall be constructed of and be supported by steel not less than 1.09 mm (0.043 in.) (No. 18 MSG) in thickness, stainless steel not less than 0.94 mm (0.037 in.) (No. 20 MSG) in thickness, or other approved material of equivalent strength and fire and corrosion resistance.
5.1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood ' s lower outermost perimeter.
5.1.3 Seams, joints, and penetrations of the hood shall be permitted to be internally welded, provided that the weld is formed smooth or ground smooth, so as to not trap grease, and is cleanable.
5.1.4* Internal hood joints, seams, filter support frames, and appurtenances attached inside the hood shall be sealed or otherwise made greasetight.

K-147
Based on observation and interview the facility failed to maintain the electrical system in accordance with NFPA 70, 1999ed. by having open electrical boxes, by having panels that are not dead front, by having non-metallic sheathed cable installed and by having unused openings in boxes. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 25 and the census was 1.
Findings Include:
Observation on 1-10-12 at 10:30 a.m. reveal a junction box above the ceiling in the south vestibule near the acute care are did not have an approved cover installed. Observation confirmed by maintenance staff.
Observation on 1-10-12 at 11:00 a.m. of the mechanical room in the Physical Therapy area revealed the electrical panel did not have the approved cover installed. Observation confirmed by maintenance staff.
Observation on 1-10-12 at 11:15 a.m. of the boiler room revealed a junction box near the west wall and conduit elbow near the south door did not have approved covers installed. Observation confirmed by maintenance staff.