HospitalInspections.org

Based on observation it was determined the facility failed to ensure there was no impediment to door closing.

The findings included:

Observation of the conference room on 11/04/14 at 7:30 A.M. revealed a wedge had been placed under the door preventing the door from self closing. With the wedge removed the door would not close and latch.

These findings were verified by the maintenance director and acknowledged by the administrator during the exit conference on 11/04/2014.

Based on observation, it was determined the facility failed to maintain 1 hour fire walls in hazardous areas.

The findings included:

1. Observations of the boiler room/mechanical room on 11/04/2014 at 8:00 A.M. revealed the walls had penetration around the piping going through the wall.

2. Observation on 11/04/2014 at 8:45 A.M. revealed the door to the file room in the operating room would not close and latch.

3. Observation on 11/04/2014 at 9:14 A.M. revealed the doors to rooms 308 and 310 did not have door closures.

4. Observation on 11/04/2014 at 9:18 A.M. revealed the walls between rooms 308 and 310 did not have a smoke resisting wall separating connecting rooms. These rooms are required smoke separation from corridor and connecting rooms.

5. Observation on 11/04/2014 at 9:25 A.M. revealed the door to the soiled linen room on the 300 hall did not close and latch.

6. Observation on 11/04/2014 A.M. at 9:31 A.M. revealed the storage room door on the senior care unit would not close and latch.

7. Observation on 11/04/2014 9:34 A.M. revealed the door to the storage room behind the nurses station would not close and latch.

Theses findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/14.

Based on observation, it was determined the facility failed to ensure all exit signs where illuminated as required.

The findings included:

Observation on 11/04/2014 at 8:28 A.M. and 9:32 A.M. revealed the exit sign in dietary and at the end of the hall in the senior care unit were not illuminated.


Theses findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/14.

Based on observation, it was determined that the facility failed to maintain the fire alarm system.

The findings included:

1. On 11/04/2014 at 8:20 the main fire alarm panel in the maintenance shop was showing a trouble signal and after going to the nurse station and looking at the fire alarm annunciator panel it showed system to be normal. When asked why was the one in the maintence shop showing trouble and the other was not, the maintenance staff said he didn't know.
When testing the primary and second phone lines on the fire alarm panel, to reset the trouble signal after testing, the wire to the battery is unplugged and a button is held down for a few seconds inside the fire alarm panel, than release the button and plug wire back to battery.
2. On 11/04/2014 at 10:15 A.M. during record review no annual fire alarm report could be provided for review.

Based on observations, it was determined the facility failed to maintain all fire sprinkler components.

The findings included:

1. Observation of the laundry room on 11/04/14 at 7:50 A.M. revealed 1 of 1 sprinkler heads with a buildup of lint and what appear to be a small wasp nest.

2. Observation on 11/04/2014 at 9:35 A.M. in the soil linen room on the 300 hall revealed the sprinkler head had blue plastic around it.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/14.

Based on observation and documentation review, it was determined 5 of 5 fire extinguishers were not inspected monthly. NFPA 10-6.2.1

The findings included:

1. Review of the monthly inspection tags on the fire extinguishers on 11/04/14 revealed the fire extinguisher in the mechanical room, purchasing room, maintenance shop, and dietary was missing the monthly inspection for the month of October 2014.

2. Observation on 11/04/2014 at 9:12 A.M. revealed the fire extinguisher at the end of the 300 hall had its last annual inspection on 3/2013.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/2014.

7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

The findings included:

Based on observation, the facility had unapproved door lock mounted on a door in boiler room.

On 11/04/2014 at 7:59 A.M. the door in the back of the boiler room has an unapproved latch mounted above the door knob lock.

Based on record review it was determined no monthly generator log could be provided for review.

The findings included:

Document review on 11/04/2014 revealed no monthly generator log for the the monthly load test could be provided for review.

Based on observation, it was determined the facility failed to maintain all electrical equipment.

The findings included:


1. On 11/04/2014 at 8:07 A.M. observation of the maintenance shop reveal an electrical outlet below the fire alarm panel was missing a cover .

2. On 11/04/2014 at 8:22 A.M. observation in the file room revealed the light cover was missing.

Theses findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/14.

Based on observation it was determined the facility failed to ensure there was no impediment to door closing.

The findings included:

Observation of the conference room on 11/04/14 at 7:30 A.M. revealed a wedge had been placed under the door preventing the door from self closing. With the wedge removed the door would not close and latch.

These findings were verified by the maintenance director and acknowledged by the administrator during the exit conference on 11/04/2014.

Based on observation, it was determined the facility failed to maintain 1 hour fire walls in hazardous areas.

The findings included:

1. Observations of the boiler room/mechanical room on 11/04/2014 at 8:00 A.M. revealed the walls had penetration around the piping going through the wall.

2. Observation on 11/04/2014 at 8:45 A.M. revealed the door to the file room in the operating room would not close and latch.

3. Observation on 11/04/2014 at 9:14 A.M. revealed the doors to rooms 308 and 310 did not have door closures.

4. Observation on 11/04/2014 at 9:18 A.M. revealed the walls between rooms 308 and 310 did not have a smoke resisting wall separating connecting rooms. These rooms are required smoke separation from corridor and connecting rooms.

5. Observation on 11/04/2014 at 9:25 A.M. revealed the door to the soiled linen room on the 300 hall did not close and latch.

6. Observation on 11/04/2014 A.M. at 9:31 A.M. revealed the storage room door on the senior care unit would not close and latch.

7. Observation on 11/04/2014 9:34 A.M. revealed the door to the storage room behind the nurses station would not close and latch.

Theses findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/14.

Based on observation, it was determined the facility failed to ensure all exit signs where illuminated as required.

The findings included:

Observation on 11/04/2014 at 8:28 A.M. and 9:32 A.M. revealed the exit sign in dietary and at the end of the hall in the senior care unit were not illuminated.


Theses findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/14.

Based on observation, it was determined that the facility failed to maintain the fire alarm system.

The findings included:

1. On 11/04/2014 at 8:20 the main fire alarm panel in the maintenance shop was showing a trouble signal and after going to the nurse station and looking at the fire alarm annunciator panel it showed system to be normal. When asked why was the one in the maintence shop showing trouble and the other was not, the maintenance staff said he didn't know.
When testing the primary and second phone lines on the fire alarm panel, to reset the trouble signal after testing, the wire to the battery is unplugged and a button is held down for a few seconds inside the fire alarm panel, than release the button and plug wire back to battery.
2. On 11/04/2014 at 10:15 A.M. during record review no annual fire alarm report could be provided for review.

Based on observations, it was determined the facility failed to maintain all fire sprinkler components.

The findings included:

1. Observation of the laundry room on 11/04/14 at 7:50 A.M. revealed 1 of 1 sprinkler heads with a buildup of lint and what appear to be a small wasp nest.

2. Observation on 11/04/2014 at 9:35 A.M. in the soil linen room on the 300 hall revealed the sprinkler head had blue plastic around it.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/14.

Based on observation and documentation review, it was determined 5 of 5 fire extinguishers were not inspected monthly. NFPA 10-6.2.1

The findings included:

1. Review of the monthly inspection tags on the fire extinguishers on 11/04/14 revealed the fire extinguisher in the mechanical room, purchasing room, maintenance shop, and dietary was missing the monthly inspection for the month of October 2014.

2. Observation on 11/04/2014 at 9:12 A.M. revealed the fire extinguisher at the end of the 300 hall had its last annual inspection on 3/2013.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/2014.

7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

The findings included:

Based on observation, the facility had unapproved door lock mounted on a door in boiler room.

On 11/04/2014 at 7:59 A.M. the door in the back of the boiler room has an unapproved latch mounted above the door knob lock.

Based on record review it was determined no monthly generator log could be provided for review.

The findings included:

Document review on 11/04/2014 revealed no monthly generator log for the the monthly load test could be provided for review.

Based on observation, it was determined the facility failed to maintain all electrical equipment.

The findings included:


1. On 11/04/2014 at 8:07 A.M. observation of the maintenance shop reveal an electrical outlet below the fire alarm panel was missing a cover .

2. On 11/04/2014 at 8:22 A.M. observation in the file room revealed the light cover was missing.

Theses findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/04/14.