HospitalInspections.org

Based on observation and record review, the provider failed to meet the minimum construction standards of the Life Safety Code. Findings include:

1. Observation revealed the building was a two story, protected, ordinary, Type III (211) structure with a wood roof, without a complete automatic sprinkler system. Document review of previous survey data confirmed that construction type.

The facility meets FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation, testing, and interview, the provider failed to maintain the smoke tight rating of corridor wall assemblies for the ground floor. One randomly observed door to the corridor would not close and latch. Findings include:

1. Observation and testing at 12:31 p.m. revealed when tested the door from the X-ray room to the corridor would not latch into the door frame on three of three attempts. Interview with the maintenance director at the time of the observation confirmed that condition. That condition was remedied by the end of the survey.

Based on observation, testing, and interview, the provider failed to maintain a 90 minute horizontal exit door in operating condition. One randomly observed set of 90 minute fire rated cross-corridor doors between the original building and the north wing did not function properly. Findings include:

1. Observation and testing at 3:38 p.m. on 4/13/10 revealed the west leaf of the cross-corridor horizontal exit doors between the original building and the north wing on the first floor would not fully close and latch under the power of the door closer. When tested that door did not close and latch on three of three attempts. Interview with the maintenance director at the time of the observation revealed he had checked that door's operation during the last months preventive maintenance check, and it had operated properly.

Based on observation and record review, the provider failed to install a complete automatic sprinkler system as required for the building construction type. Findings include:

1. Observation revealed the building was a two story, protected, ordinary, Type III (211) structure with a wood roof, without a complete automatic sprinkler system. Document review of previous survey data confirmed a complete automatic sprinkler system had not been provided.

The facility meets the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to conduct required inspections of the boilers. Two of two boilers had operation certificates that had expired. Findings include:

1. Observation at 2:45 p.m. revealed the two active boilers in the basement had operation certificates that had expired. The first boiler (#SD11163) had an operation certificate which had expired on 05/11/2007 and the second boiler (#SD11164) had a operation certificate which had expired on 12/05/2008. Those boilers had not been inspected since 12/05/2006. Interview with the maintenance director at the time of the observation revealed he was aware the two boiler certificates in the basement had expired. He stated that he was having trouble getting an inspector from the provider's new insurance company to perform the inspections.