HospitalInspections.org

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to maintain the integrity of the egress corridors. Positive latching hardware was not operational at lab door.



Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; all emergency department ' s treatment room doors in were equipped with roller latching hardware. Provide positive latching hardware on corridor doors.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to assure the integrity of the one hour enclosure. Hazardous rooms must be separated from the rest of the facility by rated 1-hour fire walls that go up to the deck and a 45 minute door with closer and positive latch. A large opening in the mechanical room opened directly into the emergency lobby ' s egress corridor plenum space.
Additionally, the third floor physical therapy ' s clean storage room was open since door did not close.


Based on observations during the survey walk of the facility on the afternoon of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to assure an acceptable enclosure of hazardous areas. Near the conference room, a corridor closet with sliding doors had been converted to a storage room of combustible material (i.e. cardboard boxes) and did not have a closure on the door and the doors were not rated and did not latch. Ensure that either the room is converted back to coat closet storing no boxes or that this room has a 1-hour fire rated enclosure (1-hour fire rated walls with 3/4-hour fire rated door assemblies with closure on doors and astragal at doors).



Based on observations during the survey walk of the facility on the afternoon of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to assure the integrity of the one hour enclosure. Rated door did not latch at 1) first floor ' s central sterile and 2) second floor biohazard in wing B and 3) second floor storage across from elevator on wing A

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to maintain protection of hazardous storage. Louvers existed in gift shop storage room ' s doors.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; protect the stairwell enclosure. Stair door did not latch and close properly at the third floor wing A NFPA 101, 2003: 8.3.3.3 ..... Unless otherwise specified, fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.1 ..... A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to provide egress direction. The existing exit sign was not visible from the sleep lab suite. This exit sign was outside the suite ' s double doors but was not visible from inside the suite since closed blinds obscured the view.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to provide safe egress out of patient room. Physical therapy patient rooms could be locked from the inside

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to provide an exit sign which marked the egress path out the building. The exit sign, located at the end of the first floor scope department egress corridor, did not indicate the direction of egress via a chevron type indicator. A sign with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to maintain the sprinkler system. Paint was on sprinkler head at 1) central supply and 2) lab and 3) maintenance department.
NFPA 13, 2002: 6.2.6.4.4.... Sprinklers that have painted or coated shall be replaced in accordance with the requirements of 6.2.6.2.2 ....Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility did not have reliable fire extinguishers. Pressure gauge reading was not fully charged at first floor ' s general mechanical room.

Based on observations during the survey walk of the facility on the afternnon of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to securely store med gas cylinders. Med gas cylinders were located on the floor with no securement at 1) mechanical room near emergency department and 2) general mechanical room. They shall be individually secured in place to meet the requirements of NFPA 99, 2002, 5.1.3.3.2(7). ..... Locations for central supply systems and the storage of medical gases shall meet the following requirements: (7) Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect, the facility failed to maintain the cleanliness of the dietary department. Two holes, opening into plenum spaces, existed in kitchen.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to maintain the type I EES system. Electrical panel boards were unlocked at first floor emergency department. This area had patients or public access.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to maintain the integrity of the egress corridors. Positive latching hardware was not operational at lab door.



Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; all emergency department ' s treatment room doors in were equipped with roller latching hardware. Provide positive latching hardware on corridor doors.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to assure the integrity of the one hour enclosure. Hazardous rooms must be separated from the rest of the facility by rated 1-hour fire walls that go up to the deck and a 45 minute door with closer and positive latch. A large opening in the mechanical room opened directly into the emergency lobby ' s egress corridor plenum space.
Additionally, the third floor physical therapy ' s clean storage room was open since door did not close.


Based on observations during the survey walk of the facility on the afternoon of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to assure an acceptable enclosure of hazardous areas. Near the conference room, a corridor closet with sliding doors had been converted to a storage room of combustible material (i.e. cardboard boxes) and did not have a closure on the door and the doors were not rated and did not latch. Ensure that either the room is converted back to coat closet storing no boxes or that this room has a 1-hour fire rated enclosure (1-hour fire rated walls with 3/4-hour fire rated door assemblies with closure on doors and astragal at doors).



Based on observations during the survey walk of the facility on the afternoon of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to assure the integrity of the one hour enclosure. Rated door did not latch at 1) first floor ' s central sterile and 2) second floor biohazard in wing B and 3) second floor storage across from elevator on wing A

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to maintain protection of hazardous storage. Louvers existed in gift shop storage room ' s doors.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; protect the stairwell enclosure. Stair door did not latch and close properly at the third floor wing A NFPA 101, 2003: 8.3.3.3 ..... Unless otherwise specified, fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.1 ..... A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to provide egress direction. The existing exit sign was not visible from the sleep lab suite. This exit sign was outside the suite ' s double doors but was not visible from inside the suite since closed blinds obscured the view.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to provide safe egress out of patient room. Physical therapy patient rooms could be locked from the inside

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to provide an exit sign which marked the egress path out the building. The exit sign, located at the end of the first floor scope department egress corridor, did not indicate the direction of egress via a chevron type indicator. A sign with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to maintain the sprinkler system. Paint was on sprinkler head at 1) central supply and 2) lab and 3) maintenance department.
NFPA 13, 2002: 6.2.6.4.4.... Sprinklers that have painted or coated shall be replaced in accordance with the requirements of 6.2.6.2.2 ....Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility did not have reliable fire extinguishers. Pressure gauge reading was not fully charged at first floor ' s general mechanical room.

Based on observations during the survey walk of the facility on the afternnon of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to securely store med gas cylinders. Med gas cylinders were located on the floor with no securement at 1) mechanical room near emergency department and 2) general mechanical room. They shall be individually secured in place to meet the requirements of NFPA 99, 2002, 5.1.3.3.2(7). ..... Locations for central supply systems and the storage of medical gases shall meet the following requirements: (7) Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect, the facility failed to maintain the cleanliness of the dietary department. Two holes, opening into plenum spaces, existed in kitchen.

Based on observations during the survey walk of the facility on the morning of 4/01/2014, with the Administrator, Chief Compliance Officer, Facilities Director from the facility and Architect; the facility failed to maintain the type I EES system. Electrical panel boards were unlocked at first floor emergency department. This area had patients or public access.