HospitalInspections.org

Based on observation and interview, the facility was a Type I/Type II building construction and the facility failed to provide/maintain interior walls/partitions that were built with noncombustible or limited combustible materials in accordance with Section 19.1.6.3 of the 2000 Life Safety Code. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
1. Observations and staff interviews on 10/25/16 at 12:07 pm, revealed a gap(approximately 1/4 inch) around a penetration located in Room 120.
2. Observations and staff interviews on 10/25/16 at 12:11 pm, revealed a hole(approximately 1 inch) located in the Shower Room by Room 126.
3. Observations and staff interviews on 10/25/16 at 12:35 pm, revealed a hole(approximately 3 inches) located on the wall in the IDF Room in the Administration Hall.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.
Findings Include:

Observations and staff interviews on 10/25/16 at 12:30 pm, revealed a large amount of combustible material being stored in Room 161. The room door opened to the corridor and the area of the room was greater that 50 sq. ft. The door was not equipped with the required self closing hardware.



Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain exits in smoke zones easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
1. Observations and staff interviews on 10/25/16 at 11:37 pm, revealed boxes and freight were being stored in the Kitchen Exit Corridor.
2. Observations and staff interviews on 10/25/16 at 12:32 pm, revealed 5 soiled linen containers were being stored in the corridor in the Patient Wing.

Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide fire drills for the staff as required by Section 19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
Observations, record review and staff interviews on 10/25/16 at 11:25 pm, revealed the facility failed to provide documentation on a second quarter fire drill for all shifts.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide/maintain the building ' s sprinkler system in reliable operating condition and/or maintain proper testing and maintenance in smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 25, Inspections, Testing, and Maintenance of Sprinkler Systems, 1998 edition, the NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1998 edition, and Sections 19.7.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
Observations and staff interviews on 10/25/16 at 11:35 pm, revealed an obstructed sprinkler head located in the Kitchen Non Food Storage Area.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide curtains/drapes/hanging fabrics in rooms in smoke zones that were in accordance with Section 10.3.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. Curtains, draperies, and loosely hanging fabrics shall be in accordance with NFPA Standard 701, Standard Methods of Fire tests for Flame Propagation of Textiles and Films. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
Observations and staff interviews on 10/25/16 at 12:00 pm, revealed the curtains located in the Physical Therapy Room did not have the required netting.
Maintenance Staff A verified these observations

Based on record review and interview, the facility failed to provide/maintain the proper testing/weekly inspections required for the building ' s Emergency Generator in accordance with Section 3.4.4.1 of the National Fire Protection Association (NFPA) Standard 99, Standard for Health Care Facilities, and Section 8.4.2 of the NFPA Standard 110, Standard for Emergency and Standby Power Systems, 1999 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:

Observations and staff interviews on 10/25/16 at 11:30 am, revealed the generator for the facility was not equipped with a remote shut off.


Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain the building ' s electrical wiring and equipment in smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:

1. Observations and staff interviews on 10/25/16 at 11:47 am, revealed two strands of decorative lights plugged into each other on the artificial tree located in the Dining Area.

2. Observations and staff interviews on 10/25/16 at 12:54 pm, revealed the electrical breakers in the electric panels in the Boiler Room were not properly identified.

Maintenance Staff A verified these observations.

Based on observation and interview, the facility was a Type I/Type II building construction and the facility failed to provide/maintain interior walls/partitions that were built with noncombustible or limited combustible materials in accordance with Section 19.1.6.3 of the 2000 Life Safety Code. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
1. Observations and staff interviews on 10/25/16 at 12:07 pm, revealed a gap(approximately 1/4 inch) around a penetration located in Room 120.
2. Observations and staff interviews on 10/25/16 at 12:11 pm, revealed a hole(approximately 1 inch) located in the Shower Room by Room 126.
3. Observations and staff interviews on 10/25/16 at 12:35 pm, revealed a hole(approximately 3 inches) located on the wall in the IDF Room in the Administration Hall.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This facility had a capacity of 25 residents and a census of 4 residents on the date of inspection.
Findings Include:

Observations and staff interviews on 10/25/16 at 12:30 pm, revealed a large amount of combustible material being stored in Room 161. The room door opened to the corridor and the area of the room was greater that 50 sq. ft. The door was not equipped with the required self closing hardware.



Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain exits in smoke zones easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
1. Observations and staff interviews on 10/25/16 at 11:37 pm, revealed boxes and freight were being stored in the Kitchen Exit Corridor.
2. Observations and staff interviews on 10/25/16 at 12:32 pm, revealed 5 soiled linen containers were being stored in the corridor in the Patient Wing.

Maintenance Staff A verified these observations.

Based on record review and interview, the facility failed to provide fire drills for the staff as required by Section 19.7.1.2 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
Observations, record review and staff interviews on 10/25/16 at 11:25 pm, revealed the facility failed to provide documentation on a second quarter fire drill for all shifts.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide/maintain the building ' s sprinkler system in reliable operating condition and/or maintain proper testing and maintenance in smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 25, Inspections, Testing, and Maintenance of Sprinkler Systems, 1998 edition, the NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1998 edition, and Sections 19.7.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
Observations and staff interviews on 10/25/16 at 11:35 pm, revealed an obstructed sprinkler head located in the Kitchen Non Food Storage Area.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to provide curtains/drapes/hanging fabrics in rooms in smoke zones that were in accordance with Section 10.3.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. Curtains, draperies, and loosely hanging fabrics shall be in accordance with NFPA Standard 701, Standard Methods of Fire tests for Flame Propagation of Textiles and Films. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:
Observations and staff interviews on 10/25/16 at 12:00 pm, revealed the curtains located in the Physical Therapy Room did not have the required netting.
Maintenance Staff A verified these observations

Based on record review and interview, the facility failed to provide/maintain the proper testing/weekly inspections required for the building ' s Emergency Generator in accordance with Section 3.4.4.1 of the National Fire Protection Association (NFPA) Standard 99, Standard for Health Care Facilities, and Section 8.4.2 of the NFPA Standard 110, Standard for Emergency and Standby Power Systems, 1999 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:

Observations and staff interviews on 10/25/16 at 11:30 am, revealed the generator for the facility was not equipped with a remote shut off.


Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain the building ' s electrical wiring and equipment in smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility had a capacity of 25 patients and a census of 4 patients on the date of inspection.
Findings Include:

1. Observations and staff interviews on 10/25/16 at 11:47 am, revealed two strands of decorative lights plugged into each other on the artificial tree located in the Dining Area.

2. Observations and staff interviews on 10/25/16 at 12:54 pm, revealed the electrical breakers in the electric panels in the Boiler Room were not properly identified.

Maintenance Staff A verified these observations.