HospitalInspections.org

K-22
Based on observation and staff interview, the facility failed to mark exit access by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. This practice affected all patients, visitors and staff that use the building. The facility census was 5 and a capacity of 21.
Findings include:
Observation on 9-20-11 at 11:50 a.m. of the south patient wing revealed the illuminated exit sign above the south exit door was not illuminated. This observation was confirmed by Maintenance staff.

K-29
Based on observation and interview the facility failed to maintain hazardous areas such that they are separated from the remainder of the building by a minimum 1 hour fire rated construction to include a 45 minute fire rated door that is self closing and positive latching, the area shall be separated from other spaces by smoke resisting partitions and doors. This practice affected all residents, staff, and visitors of the facility. The facility capacity is 21 and the census was 5.
Findings Include:
Observation 9-20-11 at 11:20 a.m. revealed the door to the south storage room and/or maintenance staff area in the basement and the door to the employee break room did not positively latch when the door was released for the mag hold open device. This observation was confirmed by Maintenance staff.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

K-45
Based on observation and interview the facility failed to maintain the minimum egress illumination of the exiting. The facility failed to illuminate a means of egress so that failure of any single bulb or fixture and did not have egress illumination connect to the facility emergency lighting circuit. This practice has the potential to affect all patients, visitors and staff of the facility that use this corridor. The facility census was 5 and a capacity of 21.

Observation on 9-20-11 at 12:30 p.m. revealed that two of the three facility ' s exits did not have a two bulb fixture light fixture installed at the exits to illuminate the egress path to the public way. This observation was confirmed by Maintenance staff.
NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

K-46
The facility failed to provide a means of illumination at each exit discharge so that failure of normal lighting would not leave the area to a public way in darkness and did provide emergency lighting at the emergency generator ' s transfer switch. This has the potential of affecting all occupants of the building in the event of a power failure. This facility has a census of 5 with a capacity of 21. Findings include:

Observation on 9-20-11 at 12:30 P.M. revealed the facility ' s egress light to the public way was not tied into the emergency generator lighting circuit. The facility ' s park area did have street lights but the lights where not controlled by the facility and not connected to the facility ' s emergency circuits. This observation was confirmed by Maintenance staff.
Observation on 9-20-11 at 11:10 a.m. revealed the facility did not have a emergency light at the emergency generator transfer switch. This observation was confirmed by Maintenance staff.
NFPA Standard: Emergency battery light for task illumination at the generator set location shall be provided. 1999 NFPA 99, 3-4.2.2.2, 3-5.2.2.2 and 3-6.2.1
NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high-rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1

K-62
Based on observation, record review and interview, the facility failed to maintain and test a complete automatic sprinkler system with weekly, monthly and quarterly inspections and testing. All smoke compartments and all occupants could be affected by the deficient practice. The facility has a capacity 21 and census was of 5. Findings include:
Observation and record review on 9-20-11 at 11:05 a.m. revealed the facility failed to provide documentation that the facility ' s automatic sprinkler system had been tested and inspected quarterly. This observation was confirmed by Maintenance staff at the time of the record review and/or exit interview.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

K-147
Based on observation and interview the facility failed to maintain the electrical system of the facility in accordance with NFPA 70, 1999ed. by having relocatable power taps in use in patient care areas, by having relocatable power taps installed as a substitute for permanent wiring and by having extension cords in permanent use. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. The facility capacity is 21 and the census was 5. Findings Include:
Observation on 9-20-11 revealed Power strip used as permanent wiring in patient rooms1,2,4,6 and 7. This observation was confirmed by Maintenance staff.
Observation on 9-20-11 of patient room 4 at 11:45 a.m.; revealed a refrigerator unit connected to the power strip. This observation was confirmed by Maintenance staff.
Observation on 9-20-11 of the facility ' s bio-hazard area at 11:25 a.m. revealed the exhaust fan motor was connected to extension cord. This observation was confirmed by Maintenance staff.