HospitalInspections.org

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 27
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/16 between 9:30 am and 12:00 pm observation revealed that: Magnetic Door in swing bed hall closing too fast. Timed at less than 3 seconds.
K-27 19.3.7. .7.75,19.3.7.6,19.3

These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 29
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that: Mechanical room located at the beginning of Administration Hall needs horizontal and vertical penetrations sealed with approved/listed intumescent fire caulk.
A. All hazardous rooms (including corridor) in the basement need all horizontal and vertical penetrations sealed with approved/listed intumescent fire caulk.
K29 - Hazardous Areas - 2000 EXISTING: One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 45.
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that: Battery back-up emergency light in the main kitchen area not working.
K45 - Illumination and Emergency Power- Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. 18.2.8, 19.2.9.1
These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 62.
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that: Ceiling above 1st stairway landing leading up to the 2nd fl. Gerri Psych ward has a ceiling tile missing directly above the fire sprinkler head. Fire sprinklers are heat activated and with the missing ceiling tile this can possibly cause heat collection not to accumulate around the fire sprinkler head, causing delay in activation.
K62 - Automatic Sprinkler Systems - Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 76.
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that the facility failed to properly store oxygen cylinders.
These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 144.
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that: No generator annunciator located in full view of the staff.
A. A remote annunciator panel must be installed where it can be monitored by staff around the clock. (Remote panel trouble indicators should at a minimum mirror the trouble indicators on the generator.
K144 - Electrical - Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99, 3.4.4.1, NFPA 110, 8.4.2

These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 27
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/16 between 9:30 am and 12:00 pm observation revealed that: Magnetic Door in swing bed hall closing too fast. Timed at less than 3 seconds.
K-27 19.3.7. .7.75,19.3.7.6,19.3

These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 29
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that: Mechanical room located at the beginning of Administration Hall needs horizontal and vertical penetrations sealed with approved/listed intumescent fire caulk.
A. All hazardous rooms (including corridor) in the basement need all horizontal and vertical penetrations sealed with approved/listed intumescent fire caulk.
K29 - Hazardous Areas - 2000 EXISTING: One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 45.
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that: Battery back-up emergency light in the main kitchen area not working.
K45 - Illumination and Emergency Power- Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. 18.2.8, 19.2.9.1
These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 62.
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that: Ceiling above 1st stairway landing leading up to the 2nd fl. Gerri Psych ward has a ceiling tile missing directly above the fire sprinkler head. Fire sprinklers are heat activated and with the missing ceiling tile this can possibly cause heat collection not to accumulate around the fire sprinkler head, causing delay in activation.
K62 - Automatic Sprinkler Systems - Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 76.
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that the facility failed to properly store oxygen cylinders.
These findings were confirmed by Staff M at the time of discovery.

ALL OTHER K-TAGS
Based on observation and staff interviews it was determined the facility failed to meet the requirements of K-Tag 144.
This could place 169 Occ. residents at risk in the event of fire.
The findings include:
On 05/03/2016 between 9:30 am and 12:00 pm observation revealed that: No generator annunciator located in full view of the staff.
A. A remote annunciator panel must be installed where it can be monitored by staff around the clock. (Remote panel trouble indicators should at a minimum mirror the trouble indicators on the generator.
K144 - Electrical - Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99, 3.4.4.1, NFPA 110, 8.4.2

These findings were confirmed by Staff M at the time of discovery.