HospitalInspections.org

This standard is not met as evidenced by:
Based on observation and interview, this facility failed to provide a construction type with a complete automatic sprinkler system. This condition affected 1 of 11 smoke compartments, and staff in the area. The facility has a capacity for 25 beds and a census of 10 on the day of the survey.

Findings include:

On 3/3/2010, at 11:00 am, during a tour of the facility, it was observed that sprinkler coverage was not provided for a Wwest Lab Corridor.
Interview on 3/3/2010, at 11:02 am, with the maintenance supervisor, revealed that he was aware that the area was not sprinkled, but that they planned on doing some remodeling of the area and when they did the remodel they would sprinkle that area at that time.

The census of 10 was acknowledged and verified by the administrator during the exit interview on 3/3/2010.

This requirement is not met as evidenced by:

Based on record review and interview, the facility failed to provide
Documentation that the draperies, curtains, including cubicle curtains, and other loosely hanging fabrics or films used as furnishings in the healthcare facility shall be flame retardant. This condition affected 11 of 11 smoke compartments, 10 patients, all visitors and staff in the area. The facility has a capacity for 25 beds and a census of 10 on the day of the survey.

On 3/3/2010, at 12:57 pm, record review revealed that there was no documentation that the draperies, curtains and other loosely hanging fabrics or films used as furnishings in the healthcare facility, were flame resistant.

Interview on 3/3/2010, at 12:58 pm, with the maintenance supervisor, revealed that he didn't know they needed to keep a record of flame resistance for the items mentioned.

The census of 10 was acknowledged and verified by the administrator during the exit interview on 3/3/2010.

This requirement is not met as evidenced by.
Based on observation and interview, the facility failed to provide protection from the extremes of the weather and from the ground beneath to prevent rusting.

During a survey of the facility on 3/3/2010, at 12:08 pm, it was observed that the oxygen cylinders that where stored outside were not protected from the extreme weather elements. and they were not protected from the ground beneath to protect from rusting.

During an interview of the maintenance supervisor on 3/3/2010, at 12:10 pm, it was revealed that they were planning on building a roof over the cylinders to protect them from the weather, but they haven't been able to complete the job yet.

The census of 10 was acknowledged and verified by the administrator during the exit interview on 3/3/2010.

This Standard is not met as evidenced by:
Based on observation and interview, the facility failed to provide a remote alarm for the emergency generator at a work site readily observable by personnel. The deficient practice affected 11 of 11 smoke compartments, all patients, visitors and staff. The facility has a capacity for 25 beds with a census of 10.

Findings are:
Observation on 3/3/2010, at 12:01 pm, revealed that the emergency generator enunciator panel that was located by the nurses' station didn't work.

Interview on 3/3/2010, at 12:03 pm, with the maintenance supervisor, revealed that he knew the enunciator panel didn't work because he was waiting for the generator company to come and attach the wires from the panel to the generator controls.

The census of 10 was acknowledged and verified by the administrator during the exit interview on 3/3/2010.

This standard is not met as evidenced by:
Based on observation and interview, this facility failed to provide a construction type with a complete automatic sprinkler system. This condition affected 1 of 11 smoke compartments, and staff in the area. The facility has a capacity for 25 beds and a census of 10 on the day of the survey.

Findings include:

On 3/3/2010, at 11:00 am, during a tour of the facility, it was observed that sprinkler coverage was not provided for a Wwest Lab Corridor.
Interview on 3/3/2010, at 11:02 am, with the maintenance supervisor, revealed that he was aware that the area was not sprinkled, but that they planned on doing some remodeling of the area and when they did the remodel they would sprinkle that area at that time.

The census of 10 was acknowledged and verified by the administrator during the exit interview on 3/3/2010.

This requirement is not met as evidenced by:

Based on record review and interview, the facility failed to provide
Documentation that the draperies, curtains, including cubicle curtains, and other loosely hanging fabrics or films used as furnishings in the healthcare facility shall be flame retardant. This condition affected 11 of 11 smoke compartments, 10 patients, all visitors and staff in the area. The facility has a capacity for 25 beds and a census of 10 on the day of the survey.

On 3/3/2010, at 12:57 pm, record review revealed that there was no documentation that the draperies, curtains and other loosely hanging fabrics or films used as furnishings in the healthcare facility, were flame resistant.

Interview on 3/3/2010, at 12:58 pm, with the maintenance supervisor, revealed that he didn't know they needed to keep a record of flame resistance for the items mentioned.

The census of 10 was acknowledged and verified by the administrator during the exit interview on 3/3/2010.

This requirement is not met as evidenced by.
Based on observation and interview, the facility failed to provide protection from the extremes of the weather and from the ground beneath to prevent rusting.

During a survey of the facility on 3/3/2010, at 12:08 pm, it was observed that the oxygen cylinders that where stored outside were not protected from the extreme weather elements. and they were not protected from the ground beneath to protect from rusting.

During an interview of the maintenance supervisor on 3/3/2010, at 12:10 pm, it was revealed that they were planning on building a roof over the cylinders to protect them from the weather, but they haven't been able to complete the job yet.

The census of 10 was acknowledged and verified by the administrator during the exit interview on 3/3/2010.

This Standard is not met as evidenced by:
Based on observation and interview, the facility failed to provide a remote alarm for the emergency generator at a work site readily observable by personnel. The deficient practice affected 11 of 11 smoke compartments, all patients, visitors and staff. The facility has a capacity for 25 beds with a census of 10.

Findings are:
Observation on 3/3/2010, at 12:01 pm, revealed that the emergency generator enunciator panel that was located by the nurses' station didn't work.

Interview on 3/3/2010, at 12:03 pm, with the maintenance supervisor, revealed that he knew the enunciator panel didn't work because he was waiting for the generator company to come and attach the wires from the panel to the generator controls.

The census of 10 was acknowledged and verified by the administrator during the exit interview on 3/3/2010.