HospitalInspections.org

Based on observation and interview, the facility failed to ensure that meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for construction type and supporting construction for health care and/or other building occupancies. A 2-hour separation was not provided in accordance with section 8.2.1.3 on all 4 floors which is a deficiency in the Nursing Facility.

On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following:

1. Fire stopping was found missing or in need of repair in the following locations above ceiling:
MH1008
MH1017g
MH1014
MH1044
MH1056


The surveyors confirmed this finding with the engineering supervisor at the time of the observation.

Based on observation and interview, the facility failed to ensure that Access-Controlled Egress Door assemblies are installed in accordance with 7.2.1.6.2 of NFPA 101 2012 edition and that doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side.

On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following:

1. Exit door MH000 is equipped with a push to exit button, but is not equipped with the required approach sensor to unlock the door from the egress side. The push to exit button is to be used as a failsafe in conjunction with the approach sensor.
2.On the exit door nearest the lobby side leaving the ED a thumbturn lock is installed.

The surveyors confirmed this finding with the engineering supervisor at the time of the observation.

Based on observation, the facility failed to ensure that doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 of NFPA 101 2012 edition that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following:

1. Doors MH1020 and MH1038, self-closing doors, are prevented from closing by use of manually operated foot pegs.

The surveyors confirmed this finding with the engineering supervisor at the time of the observation.

Based on observation, the facility failed to ensure that Ramps, exit passageways, fire and slide escapes, alternating tread devices, and areas of refuge are in accordance with the provisions 7.2.5 through 7.2.12. 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10 of NFPA 101 2012 edition

On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following:

1. In the basement east stair near the morgue, a ramp has been installed and the placement of the handrails has not been modified to meet the requirements of chapter 7 of NFPA 101 2012 edition.

The surveyors confirmed this finding with the engineering supervisor at the time of the observation.

The facility failed to protect hazardous area fire barrier walls and ceiling, having 1-hour fire resistance rating in accordance with NFPA 101 2012 edition Section 19.3.5.9 and that Doors shall be self-closing or automatic-closing and permitted to have non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.

Findings:

On 04/03/2024 between hours of 9:45 am and 1:00 pm. surveyors accompanied with Engineering Supervisor observed the following:

1. In the universal hazardous waste storage room MH008e a piece of wood was found covering a hole in the ceiling.

2. Rooms labeled MH1024 and MH1052 are being used as storage rooms and require self-closing doors.

The Surveyors confirmed these findings with the Engineering Supervisor at the time of observation.

Based on observation, the facility failed to ensure that hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 2010 edition, Standard for the Installation of Sprinkler Systems.

On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following:

1. Sprinkler system coverage does not extend to the K0351 area surrounding the CT trailer.


The surveyors confirmed this finding with the engineering supervisor at the time of the observation.

Based on observation, the facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems.

On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following:

1. The center sprinkler head in the cafeteria in the basement was missing the escutcheon plate.

2. Storage rooms MH1031 and MH027 items were found stored withing 18" of a sprinkler head. This was corrected during the survey.


The surveyors confirmed this finding with the engineering supervisor at the time of the observation.

Based on observation, the facility failed to ensure that Fire doors assemblies are inspected and tested annually in accordance with NFPA 80 2010 edition, Standard for Fire Doors and Other Opening Protectives.

On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following:

1. Fire door MH1035 is equipped with lower latches that were not functioning correctly and did not completely latch.


The surveyors confirmed this finding with the engineering supervisor at the time of the observation.

Based on observation, the facility failed to ensure that Storage locations of oxygen cylinders are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.

On 4/3/2024, between 9:45 AM and 1:00 PM, surveyors, with the Engineering supervisor present, observed the following:

1. 13 e-tanks were found stored in a room equipped and designed for storage of 12 or less e-tanks.

The surveyors confirmed this finding with the engineering supervisor at the time of the observation.