HospitalInspections.org

K-18 Not Met

This standard is not met as evidenced by:

Based on observations, the facility failed to provied doors protecting corridor openings in accordance with 19.3.6.3.3. This condition had the potential to affect 100% of the residents and staff.

Findings Include;

On April 27, 2011 at 9:30 a.m, the maintenance person and the surveyor found that the corridor doors had air transfer grills in the bottom doors in order to use the corridor as part of the return air plenum for the HVAC system.. The facility is fully sprinkled and the HVAC system shuts down upon activation of the fire alarm system. This deficient practice has the potential of affecting 2 of 2 smoke compartments.
The administrative assistant and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the smoke resisting partitions and doors in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 25% of the residents and staff or two (2) of two (2) smoke compartments.

Findings include:

On April 27, 2011 at approximately 10:30 a.m., the maintenance person and the surveyor found the following deficiencies in hazardous areas:

1. The boiler room located on the west side of the building had unsealed penetrations in the walls and ceiling.

2. The boiler room located in the kitchen had unsealed penetrations and lacked a door closure.

This deficient practice has the potential of affecting two (2) of two (2) smoke compartments. The administrative assistant and maintenance director were notified during the survey and at the exit conference.

Based on observations the facility failed to provide the required Fire drill documentation as per NFPA 101 chapter 18.7.1.2, 19.7.1.2. This condition had the potential to affect 100% of the residents and staff.

Findings include:

While reviewing fire drill documentation on April 27, 2011 at approximately 11:00 a.m., the surveyor observed the facility did not provide fire drill information for past fire drills including date, time, what shift, and personnel attending the fire drill. No documentation was provided for every shift.

The administrative assistant and the maintenance director were notified during the survey as well as the exit conference.

Based on observation and testing, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building in accordance with section 9.7. This condition affected 100% of the residents and staff of the building.

Findings include:

On April 27, 2011 at approximately 11:30 a.m., the maintenance person and surveyor found following areas lacked sprinkler heads:

1. The covered porch in front of the building lacked sprinkler heads on the newer addition.

2. The covered smoking area on the east side of the building lacked sprinkler heads on the newer addition.

This deficient practice has the potential of affecting two (2) of two (2) smoke compartments. The administrator assistant and the maintenance director were notified during the survey and in the exit conference.

Part A

Based on observation and record review, the facility failed to properly test and maintain the automatic sprinkler system contrary to NFPA 13, NFPA 25. This condition affected 100% of the residents and staffs as all smoke compartments were affected.

Findings include:

On April 27, 2011 at approximately 11:45 a.m., the facility could not provide documentation stating that they had performed the quarterly test on the sprinkler system. The maintenance supervisor advised that he was not aware that this had to be done quarterly.

The administrative assistant and maintenance supervisor were notified during the survey and in the exit conference.

Part B

Based on record review, the facility failed to properly insure the operability of the sprinkler system as required by NFPA 13 5-5.5.1. This condition affected 100% of the residents and staff.

Findings include:

On April 27, 2011 at approximately 12:15 p.m., the maintenance person and surveyor found two (2) sprinkler heads located at the entrance to the clinic to be blocked. The heads were blocked by the lights.

This deficient practice has the potential of affecting three (3) of six (6) smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required monthly generator testing in accordance with NFPA 99.

Findings include:

While reviewing generator testing documentation on April 27, 2011 at approximately 12:30 a.m., the facility failed to provide the monthly generator load testing documentation for the months of June, August, September, and November in 2010 and also for the months of February and March, 2011.

This deficient practice has the potential of affecting the entire facility. The administrative assistant and the maintenance director were notified during the survey as well as the exit conference.