HospitalInspections.org

Based on observation and staff interview, the facility is not providing doors to the corridor that stay latched tightly within the doorframes. This deficient practice would not prevent the spread of smoke, affecting all occupants and 10 residents in in one of five smoke zones. This facility has a capacity of 50 with a census of 30 residents.

Findings include:

1. Observation and interview on 6/11/12, revealed the door to Room #301 would not stay closed tightly within the doorframe due to faulty latching.

2. Observation and interview on 6/11/12, revealed the door to the Physical Therapy room had a 1 inch gap around the door when closed.

Maintenance Staff A confirmed these observations.

NFPA Standard: Doors in corridor walls shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed per 2000 NFPA 101, 19.3.6.3.1

Based on observation and interview, this facility is not assuring that two of six smoke barriers is free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and 0 residents in two of five smoke zones. This facility has a capacity of 50 with a census of 30 residents.

Findings include:

Observation and interview on 6/11/12 and 6/12/12, revealed the following:

1. The Smoke Barrier by the Pharmacy had 2 inch by 3 inch penetrations around two pipes. According to the facility layout, this was a required barrier.

2. The Smoke Barrier by the East Equipment room had a large 8 inch by 8 inch penetration. According to the facility layout, this was a required barrier.

Maintenance Staff A confirmed these observations.

NFPA standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on record review and staff interview, the facility failed to properly test the emergency task lighting in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.9.3. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. This deficient practice affects all occupants of the facility. This facility has a capacity of 50 and a census of 30 residents.

Findings include:

Record review of the facility's maintenance records and staff interview on 6/11/12 and 6/12/12, revealed the facility was unable to provide documentation to show the emergency task battery lighting had been provided with the monthly 30 second test and the annual 1 1/2 hour test. Maintenance Staff A confirmed this test had not been completed at the time of the survey process.

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This deficient practice can place all occupants at risk in the event of a fire. The census was 50 with a capacity of 30 residents.

Findings include:

Observation and interview on 6/11/12 and 6/12/12, revealed there were only five extra sprinkler heads for the sprinkler system. This observation was verified with Maintenance Staff A.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This can affect the operation of the heads by delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants in the Kitchen/Dining area at risk in the event of a fire. The census was 50 with a capacity of 30 residents.

Findings include:

Observation and interview on 6/11/12 and 6/12/12, revealed the sprinkler head in the refrigerator in the Kitchen was missing the escutcheon plate. This observation was verified with Maintenance Staff A.


NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4


NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. NFPA 25, 1-11.3

Based on observation and interview the facility could not provide documentation that the plastic window blinds were flame resistant. This has the potential of affecting all occupants, staff, visitors and 4 residents in one of five smoke zones . This facility has a capacity of 50 and a census of 30 residents.

Findings include:

Observations and interview on 6/11/12 and 6/12/12, revealed the mini blinds in the Dialysis Contract Office were not metal and were not tagged as being flame retardant. Maintencnace Staff A confirmed these observations.

NFPA Standard: Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. 2000 NFPA 101, 10.3.1

Based on observation and interview the facility did not provide emergency lighting at the generator location. This deficient practice affects all occupants in the building. The facility has a certified capacity of 50 and the census at the time of the survey was 30 residents.

Findings include:

Observation and interview on 6/11/12 and 6/12/12, revealed the generator did not have emergency lighting in the location (room) it was located in. Maintenance Staff A verified this finding.

Based on observation and interview, the facility failed to maintain all alcohol based hand rub dispenser in accordance with 2000 Life Safety Code 19.3.2.7. This deficient practice affects all occupants in the Material Management area. The facility has a certified capacity of 50 with the current census of 30 residents.

Findings include:

Observation and interview on 6/11/12 and 6/12/12, revealed a alcohol based hand rub dispenser over the light switch in the Material Management Area. Maintenance Staff A verified this finding.