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Based schematic review, observation, and staff verification the facility failed to ensure 2 hour occupancy separations were free of penetrations. This has the potential to affect all patients in the facility.

Findings include:

Observation of the west 2 hour fire rated occupancy separation, on the 2nd floor, completed on 10/31/17 at 9:52 AM, as seen from the healthcare side, revealed an 8 inch by 16 inch section of concrete block busted out to the left of a gypsum board area and a 8 inch by 8 inch sections of concrete block busted out to the right of a gypsum board area.

This finding was verified by Staff B at the time of the observation.

Based on occupancy permit review, and observation the facility failed to ensure the facility's construction type was permitted as per NFPA 101. This has the potential to affect all patients at the facility.

Findings include:

Review of the occupancy permit dated 10/26/17 completed on 10/30/17 revealed the construction type was identified as V-B which correlated to type V (000) for NFPA 101. The construction drawings provided had a date of drawing completion of 10/2016.

Observation of the attic space completed on 10/31/17 revealed non-fire treated wood construction for the ceiling and roof support structure. Sprinklers were noted in the attic space at the time of the observation.

Based on observation and staff verification the facility failed to ensure all the exits are of a hard packed all-weather travel surface. This has the potential to affect all patients in the facility.

Findings include:

Observation of the East exit completed on 10/31/17 revealed a 4 foot by 4 foot concrete pad. When stepping off of the pad there was approximately 75 feet of grass to get to another hard packed surface.

This finding was verified by Staff B at the time of the observation.

Based on observation and staff verification the facility failed to ensure all the exits are of a hard packed all-weather travel surface. This has the potential to affect all patients in the facility.

Findings include:

Observation of the North exit completed on 10/31/17 revealed a 4 foot by 4 foot concrete pad. When stepping off of the pad there was approximately 75 feet of grass to get to another hard packed surface.

This finding was verified by Staff B at the time of the observation.

Based on observation and staff verification the facility failed to ensure all the exits are of a hard packed all-weather travel surface. This has the potential to affect all patients in the facility.

Findings include:

Observation of the South exit out of the dining room area completed on 10/31/17 revealed a large concrete patio. When stepping off of the pad there was approximately 50 feet of mud to get to another hard packed surface.

This finding was verified by Staff B at the time of the observation.

Based on documentation review, and staff verification the facility failed to ensure that the battery backup emergency light testing was documented for each emergency light. This has the potential to affect all patients at the facility.

Findings include:

Review of the Battery backup lighting annual and monthly testing completed on 11/02/17 revealed the document didn't identify how many emergency battery lights were tested and the location of each light. The documents stated all lights working.

Interview with Staff B completed on 11/02/17 at 11:00 AM revealed there are 4 lights in the entire building stated that they are not individually placed on the form because of so few.

Based on observation and staff verification the facility failed to ensure hazardous areas ceiling and wall smoke partition were free of penetrations. This has the potential to affect all patients in the facility.

Findings include:

Observation of the Furnace room completed on 10/31/17 revealed a 1/2 inch conduit with open annular space, and a 1 1/2 inch pipe, with cables passing through, open on the end. both penetrating the gypsum board ceiling.

These findings were verified by Staff B at the time of the observations.

Based on observation and staff verification the facility failed to ensure hazardous areas ceiling and wall smoke partition were free of penetrations. This has the potential to affect all patients in the facility.

Findings include:

Observation of the Furnace room completed on 10/31/17 revealed a 2x4 inch electrical box penetrating the wall above the hot water tank.

These findings were verified by Staff B at the time of the observation.

Based on observation and staff verification the facility failed to ensure hazardous areas ceiling smoke partition is free of penetrations and doors on self closing devices are kept in a closed position. This has the potential to affect all patients in the facility.

Findings include:

Observation of the Laundry room located on the second floor completed on 10/31/17 revealed 2 electric dryers, the door was noted to be on a self closing device but the door was being propped open with a trash can. Two dryer vents were noted to pass through the gypsum board ceiling. The space around the vents were noted to not be sealed. On 11/02/17 the door was noted to be propped open again with a trash can when walking through the second floor.

These findings were verified by Staff B and Staff A at the time of the observations.

Based on observation and staff verification the facility failed to ensure hazardous areas fire rated ceiling and walls were free of penetrations. This has the potential to affect all patients in the facility.

Findings include:

Observation of the Laundry room completed on 10/31/17 revealed multiple penetrations varying in size and shape of all walls as seen from within the laundry room. These findings were verified by Staff B at the time of the observation.

Observation of the Laundry room wall as seen from the corridor completed on 10/31/17 revealed multiple penetrations varying in size and shape. These findings were verified by Staff B at the time of the observation.

Observation of the East Mechanical room completed on 10/31/17 revealed multiple penetrations in the fire rated ceiling varying in size and shape and a 1/2 inch conduit with open annular space, and a 6 inch water line with open annular space penetrating the South wall with open annular space.

These findings were verified by Staff B at the time of the observation.

Based on documentation review and staff verification the facility failed to ensure sensitivity testing, visual inspections, and annual functional testing was completed for all duct and photo detectors. Also no documentation of visual and functional testing of the visual and auditory signaling devices, and the functional testing of the magnetic door releasing devices were completed. This has the potential to affect all patients in the facility.

Findings include:

Review of the Alarm Inspection and Testing Form dated 04/13/17 completed on 11/02/17 revealed 8 identified duct detectors and 70 photo detectors. Review of the documentation did not show the visual inspections were completed on the photo detectors or duct detectors, no listing of each individual detectors as visually inspected was noted. A document was provided of the photo detector functional testing, no duct detectors were noted on the testing provided. Review of the sensitivity testing revealed only 2 of the 8 duct detectors had sensitivity testing completed and passed. A note was written on the inspection and testing form stating door holders with an arrow pointing to the section check marked for completion of visual and functional testing. The document does not state how many hold open devices were inspected and tested, or their locations.

These findings were verified by Staff A at the time of the documentation review.

Based on observation and staff verification the facility failed to ensure the type V (000) construction was protected throughout by a sprinkler system. This has the potential to affect all patients at the facility.

Findings include:

Observation of the attic space completed on 10/31/17 revealed the attic space was not sprinklered.

Staff B confirmed there were no sprinkler heads in the attic space at the time of the observation.

Based on observation and staff verification the facility failed to ensure the type V (000) construction was protected throughout by a sprinkler system. This has the potential to affect all patients at the facility.

Findings include:

Observation of the attic space completed on 10/31/17 revealed the attic space was not sprinklered. Staff B confirmed there were no sprinkler heads in the attic space at the time of the observation.

Based on schematic review, observation, and staff verification the facility failed to ensure the building was divided into at least two smoke compartments with a fire rated smoke barrier. This has the potential to affect all patients in the facility.

Findings include:

Review of the schematic completed on 10/30/17 revealed no fire rated smoke barrier was noted that traveled from outside wall to outside wall. This finding was verified by Staff B on 10/31/17.

Observation of the building completed on 10/31/17 revealed the building had 32 beds and no wall was noted separating the building into two smoke compartments.

Staff B verified there was no fire rated smoke barrier in the building.

Based on documentation review and staff verification the facility failed to ensure to conduct fire drills quarterly on every shift at varying times. This has the potential to affect all patients at the facility.

Findings include:

Review of the fire drill documentation for the last 2 quarters of 2016 and up to the current time frame of 2017 revealed 3 fire drills were completed for a 12 month period for 1st shift and the times of the fire drills were within a 16 minute time frame. The fire drills were completed on 12/28/16 at 1:58 PM, 03/29/17 at 2:15 PM, and 06/22/17 at 2:08 PM. The review also revealed 2 fire drills were completed for a 12 month period and both fire drills were completed at 6:50 PM on 08/30/16 and 02/23/17.

These findings were verified by Staff A at the time of the documentation review.

Based on tour of the facility and staff interview the facility failed to ensure a remote annunciator panel was located in a readily observed area. This has the potential to affect all patients at the facility.

Findings include:

Tour of the facility completed 10/31/17 through 11/01/17 revealed no remote annunciator panel was noted in the building.

Interview with Staff B completed on 11/01/17 at 11:43 AM revealed there is no remote annunciator panel for the generator located in a readily observable area.

Based on tour of the facility and staff interview the facility failed to ensure a remote annunciator panel was located in a readily observed area. This has the potential to affect all patients at the facility.

Findings include:

Tour of the facility completed 10/31/17 through 11/01/17 revealed no remote annunciator panel was noted in the building.

Interview with Staff B completed on 11/01/17 at 12:00 PM revealed there is no remote annunciator panel for the generator located in a readily observable area.

Based on documentation review and staff verification the facility failed to ensure the monthly generator testing was completed at 30 percent name plate rating for 30 minutes. This has the potential to affect all patients in the facility.

Findings include:

Review of the "Monthly Emergency Generator Test" dated 10/27/17 completed on 11/02/17 revealed the generator Amps were 150 when tested, the document stated that it must be at 226 Amps to meet NFPA 30% name plate rating. Previous months were reviewed and none of the months met the 30% name plate rating identified on the inspection documentation. A request was made for annual 2 hour load bank testing.

On 11/02/17 Staff A stated that no annual testing was completed for the generator.

Based on documentation review and staff verification the facility failed to ensure the monthly generator testing was completed at 30 percent name plate rating for 30 minutes. This has the potential to affect all patients in the facility.

Findings include:

Review of the "Monthly Emergency Generator Test" dated 10/27/17 completed on 11/02/17 revealed the generator Amps were 24 when tested, the document stated that it must be at 226 Amps to meet NFPA 30% name plate rating. Previous months were reviewed and none of the months met the 30% name plate rating identified on the inspection documentation. A request was made for annual 2 hour load bank testing.

On 11/02/17 Staff A stated that no annual testing was completed for the generator.

Based on documentation review and staff verification the facility failed to ensure the monthly generator testing was completed at 30 percent name plate rating for 30 minutes. This has the potential to affect all patients in the facility.

Findings include:

Review of the "Monthly Emergency Generator Test" dated 10/27/17 completed on 11/02/17 revealed the generator Amps were 34 when tested, the document stated that it must be at 226 Amps to meet NFPA 30% name plate rating. Previous months were reviewed and none of the months met the 30% name plate rating identified on the inspection documentation. A request was made for the annual 2 hour load bank testing.

On 11/02/17 Staff A stated that no annual testing was completed for the generator.