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Tag No.: K0011
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to provide 2-hour rated construction at building separation wall in accordance with 2000 - NFPA 101, sections 19.1.1.4.1 and 8.2.3.2. The deficient practice could affect all 7 patients.
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, observation revealed, that the 2-hour rated building separation wall between hospital and nursing home, has open penetrations above the ceiling by the beauty shop.
This deficient practice was confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
Tag No.: K0025
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to maintain smoke barrier wall in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3, and 8.3.4.1. The deficient practice could affect all 7 patients
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, observation revealed, that the smoke barrier wall by room the Diabetes Education office, has open penetrations above the drop in ceiling.
All smoke barriers throughout the facility needs to be checked.
This deficient practice was confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
Tag No.: K0029
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to maintain the hazardous rooms in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1 . The deficient practice could affect all 7 patients.
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, observation revealed that the following was found:
1. 1st floor - Laundry storage room, there is a 12 inch by 12 inch hole in the ceiling
2. 1st floor - volunteer storage room (over 50 square feet), is not a one hour fire rated room
3. 1st floor - Boiler room, open penetrations on west wall
These deficient practices were confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
Tag No.: K0038
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to provide means of egress in accordance with the following requirements of 2000 NFPA 101, Section 19.2.1 and 7.7.1. The deficient practice could affect all 7 patients
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, observation revealed, that the required exit discharge by the maintenance directors office, does not have a continuous hard path to public way.
This deficient practice was confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
Tag No.: K0046
2000 NFPA 101 LIFE SAFETY CODE STANDARD
Emergency lighting of at least 1-1/2 hour duration is provided in accordance with 7.9, 18.2.9.1, 19.2.9.1
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9. The deficient practice could affect all patients in these locations.
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, the review of the emergency lighting and exit sign testing documentation for the past 12 months revealed, that the facility failed to conduct monthly and yearly testing and document such.
This deficient practice was confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
Tag No.: K0050
This STANDARD is not met as evidenced by:
Based on documentation review, the facility failed to assure fire drills were conducted once per shift for all staff under varying times and conditions as required by 2000 NFPA 101, Section 18.7.1.2.
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, the review of the fire drill documentation for the past 12 months revealed, that the facility failed to conduct fire drill.
This deficient practice was confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.
Tag No.: K0050
This STANDARD is not met as evidenced by:
Based on documentation review, the facility failed to assure fire drills were conducted once per shift for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, the review of the fire drill documentation for the past 12 months revealed, that the facility failed to conduct fire drill.
This deficient practice was confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.
Tag No.: K0052
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to install the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Section 2-3.5.1. The deficient practice could affect all 7 patients.
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, observation revealed, that the following smoke detectors were place with-in 3 feet of air supply or return vent:
1. 1st floor - Mail / copier room
2. 1st floor - Operating room # 3
3. 1st floor - Housekeeping storage room by lab
NOTE: the whole facility needs to be checked for this deficiency
These deficient practices were confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
Tag No.: K0056
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to provide proper coverage of the fire sprinkler system as per 1999 NFPA 13 Sections 3-2.7 and 5-13.6. The deficient practice could affect all 7 patients.
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, observation revealed, that the following was found:
1. Basement - elevator equipment room and pit area for elevator "A", does not have fire sprinkler protection. Follow all requirements for shunt trip and heat detector.
2. 1st floor - elevator equipment room and pit area for elevator "B" and "C", does not have fire sprinkler protection. Follow all requirements for shunt trip and heat detector.
3. Escutcheon plates are missing throughout the facility
These deficient practices were confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
Tag No.: K0077
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99 Chapter 4-3.5.2.3 (i). The deficient practice could affect all 7 patients.
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, the review of the medical gas alarm system testing documentation revealed, that the testing of audible and visual alarm indicators have not been tested in the past 12 months.
This deficient practice was confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
Tag No.: K0144
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to have the emergency generator installed per NFPA 70 - Article 700-12 and 2000 NFPA 101. This deficient practice could affect all 7 patients.
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, observation revealed that the emergency generator located outside the building does not have an audible and visual alarm that can be heard or seen at a 24 hours a day location
This deficient practice was confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
Tag No.: K0147
This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to install isolated power systems per 2000 NFPA 101 -19.3.2.3, 1999 NFPA 99 3-3.2.1 and 1999 NFPA 70 - Article 517-20(a).
Findings include:
On facility tour between 9:00 AM and 4:45 PM on 07/22/2010, observation revealed that in operating room # 3, there was no isolated power system. The Maintenance Director (DD) and and Vice-President of Finance (JD), could not tell me if the operating rooms are considered wet or dry locations. We spoke to the supervisor of the area (CF) and she explained to us that all three operating rooms are considered wet and they can not tolerate electrical circuit interruptions during surgeries.
This deficient practice was confirmed by the Maintenance Director (DD) and and Vice-President of Finance (JD) at the time of discovery.
*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.