HospitalInspections.org

Based on observation and interview, the facility failed to ensure activity spaces open to the corridor was protected by an electrically supervised automatic smoke detection system. This has the potential to affect all patients in the buildings. The census in the building was 16 patients.

Findings include:

On 07/18/16 at 1:08 PM a tour was taken of the building with Staff Q.

On 07/18/16 at 1:19 PM observation of the multipurpose room by the northeast entrance/exit revealed it had an opening to the corridor without a door. The room was observed to have sprinklers and was not observed to have a smoke detector. The southern and southeast portion of the room was not visible to the nursing station.

On 07/18/16 at 1:19 PM in an interview, Staff Q confirmed the observation.

On 07/18/16 at 2:31 PM observation of the tv/group room revealed it had an opening to the corridor without a door. The room was observed to have sprinklers and was not observed to have a smoke detector. Parts of the room were unobservable from the corridor.

On 07/18/16 at 2:31 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each door protecting corridor openings had a working, suitable means for staying closed. This has the potential to affect all patients at the facility. The patient census in the building was 16 patients.

Findings include:

On 07/18/16 at 1:08 PM a tour was taken of the facility with Staff Q.

On 07/18/16 at 3:12 PM the door to the visitor ' s bathroom located in the service corridor was observed to be self-closing and having latching hardware that when tested did not close and latch the door.

On 07/18/16 at 3:12 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure window openings on the corridor had windows. This has the potential to affect all patients in the buildings. The census in the building was 16 patients.

Findings include:

On 07/18/16 at 1:08 PM a tour was taken of the building with Staff Q.

On 07/18/16 at 1:19 PM observation of the multipurpose room by the northeast entrance/exit revealed it was missing a window. A frame was for an approximate one foot by four foot window was observed, but the window was not.

On 07/18/16 in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure its smoke barriers were free of penetrations. This has the potential to affect all patients at the facility. The census in the building was 25 patients.

Findings include:

On 07/19/16 at 9:03 AM a tour was taken of the facility with Staff Q.

On 07/19/16 at 9:55 AM observation above the solid ceiling of the northern east/west barrier as seen through an access panel in the dining room revealed a two inch penetration with a bundle of blue wires traveling through it.

On 07/19/16 at 9:55 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each door opening in the smoke barrier had a door. This has the potential to affect all patients in the buildings. The census in the building was 16 patients.

Findings include:

On 07/18/16 at 1:08 PM a tour was taken of the building with Staff Q.

On 07/18/16 at 2:25 PM observation of the east/west smoke barrier revealed it ran along the bathroom in room 56. The opening to the bathroom was observed within the smoke barrier and without a door.

On 07/18/16 at 2:25 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each door to a hazardous area that had a self-closer could self-close. This has the potential to affect all patients in the buildings. The census in the building was 16 patients.

Findings include:

On 07/18/16 at 1:08 PM a tour was taken of the building with Staff Q.

On 07/18/16 at 2:06 PM observation of two, separate doors to the kitchen, one in the west wall, the other in the south wall, revealed both had self-closers and both were propped open. One was propped open with a table, the other with a block of wood. No staff was present in the kitchen at the time of the observation. Each door was observed to have a sign that read in part to keep the doors closed before leaving the room.

On 07/18/16 at 2:06 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to have installed a supervisory attachment installed to each of the control valves per NFPA 101, 9.7.2, specifically the control valves observed in the kitchen storage area. This has the potential to affect all patients at the facility. The patient census in the building was 16 patients.

Findings include:

On 07/18/16 at 1:08 PM a tour was taken of the facility with Staff Q.

On 07/18/16 at 3:04 PM two sprinkler system control valves were observed in the kitchen storage area. They were observed to have plastic cuffs and no supervisory attachment.

On 07/18/16 at 3:04 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure it had spare sprinklers of the type in use. This has the potential to affect all patients in the buildings. The census in the building was 16 patients.

Findings include:

On 07/18/16 at 1:08 PM a tour was taken of the building with Staff Q. Throughout the tour the sprinkler system was observed to have pseudo-flush sprinkler heads in place.

On 07/18/16 at 2:47 PM observation of the spare heads at the sprinkler riser room did not reveal any spares of this type of head.

On 07/18/16 at 2:47 PM in an interview, Staff Q confirmed the finding.

Based on interview, observation, and record review, the building failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients, staff, and visitors to the building. This has the potential to affect all patients in the buildings. The census in the building was 16 patients.

Findings include:

On 07/18/16 at 1:08 PM a tour was taken of the building with Staff Q.

On 07/18/16 at 2:25 PM observation above the solid ceiling of smoke barrier as seen from an access panel in the closet of room 56 revealed a damper in place in the heating, ventilation, and cooling duct.

On 07/18/16 at 2:25 PM in an interview, Staff Q confirmed the finding.

On 07/19/16 a review of the building ' s life safety code documentation was completed. The review revealed dampers were tested, but did not revealed where the damper in the closet of room 56 was tested.

Based on observation and interview, the facility failed to keep space heaters out of patient care areas. This has the potential to affect all patients at the facility. The census in the building was 25 patients.

Findings include:

On 07/19/16 at 9:03 AM a tour was taken of the facility with Staff Q.

On 07/19/16 at 9:28 PM two space heaters were observed in room 128.

On 07/19/16 at 9:37 AM one space heater was observed in the therapist office.

All three were in the same smoke compartment as shared with sleeping patients.

On 07/19/16 at 9:37 AM in an interview, Staff Q confirmed the finding.

Based on interview and observation, the facility failed to ensure each means of egress was continuously maintained free of all obstructions or impediments to full instant use. This has the potential to affect all patients at the facility. The census in the building was 25 patients.

Findings include:

On 07/19/16 at 9:03 AM a tour was taken of the facility with Staff Q.

On 07/19/16 at 9:58 AM an exit door was observed at the nursing station. In front of the exit door a mobile rack of charts was observed protruding about one foot into the plane of the door.

On 07/19/16 at 9:58 AM in an interview, Staff Q confirmed the finding.

On 07/19/16 at 1:00 PM observation of the north exit revealed the exit discharge terminated at a concrete pad. Beyond the concrete pad a grassy field lay between it and a path of common way.

On 07/20/16 at 2:00 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to ensure its generator was maintained in accordance with NFPA 99 and 110, 1999 editions. This has the potential to affect all patients, staff, and visitors to the facility. The census in the building was 25 patients.

Findings include:

Review of the facility's life safety code documentation was completed on 07/19/16.

Review of the service for the generator for the building revealed planned maintenance document completed on 06/08/16. The review revealed "normal position light is burnt out on both ATS's recommend replacing" and power and control wiring was marked as needing attention.

On 07/19/16 at 1:45 PM in an interview, Staff Q stated the process was started to repair the generator, but the generator was not yet fixed.