HospitalInspections.org

K-17 Not Met.
Findings. Door to storage room medical surgical wing is not latching as required.This condition observed and identified to hospital engineer by Inspector.

K-20 Not Met.
Findings: the fire door at the top of west exit stair to corridor( Med Surg wing) is not properly self-closing or latching. This condition observed by Inspector and identified to Hospital engineer.

K-29 Not Met.
Findings: Soiled utility rooms not properly protected as required ( 2 Locations)
a. Door to soiled utility room basement level has an approximately 3/4 inch gap at the door frame side.
b. Doors(2) soiled utility room Med Surg Wing are not provided with latching devices.
This condition observed by Inspector and identified to Hospital engineer.

K-38 Not Met.
Findings: The entrance from west exit stair to MRI area had a 3 inch step up to the ramp serving the MRI trailer that created a potential tripping hazard and exceeded the 1/2 inch allowable change in elevation of walking surfaces in a means of egress.
This condition observed by Inspector and identified to the Hospital engineer.

K-48 Not Met.
Findings: A written copy of the facilities emergency fire and evacuation plan was not available to supervisory personnel in the Cardiac Care Unit.
Inspector asked for a copy of the plan and employees were unable to locate it.
This condition was acknowledged by the Hospital engineer.

K-61 Not Met
Findings: While reviewing the facilities maintenance records Inspector observed the sprinkler companies reports and found that the service technician recorded that the sprinkler tamper switch was not working on 3 of 4 quarterly reports and at the time of this inspection this condition has not been corrected.
The Hospital Administrator was made aware of the condition at a meeting 3/2/2010 1630 hrs.

K-62 Not Met.
Findings: While reviewing the facilities maintenance records Inspector observed that the sprinkler service report indicated that the outside sprinkler warning bell was not functioning on more than 1 quarterly report. This condition at the time of the inspection has not been corrected.
The Hospital Administrator was made aware of the condition at a meeting 3.2/2010 1630 Hrs.

K-69 Not Met.
Findings: Cafeteria and main kitchen cooking equipment ( fry-olators) are positioned less than 18 inches from grills and sources of ignition that can produce vapor laden grease fires. NFPA 96 section 9.1.2.3.
This condition acknowledged by the Hospital engineer.

Findings: The hood in the cafeteria does not have an approved grease collection cup for the filter channel.

Findings: The gas piping and areas behind the cooking equipment have considerable grease accumulation.

K-77 Not Met.
Findings: Outside storage of medical oxygen supply shall have gates and enclosures that are capable of being locked. NFPA 99 section 4-3.1.1.2 paragraph 11 item c. The lock on the chain was found unlocked.
Hospital engineer observed and acknowledged this condition.

K-130 Not Met.
Findings: The following deficiencies were observed while surveying the hospital offsite locations with hospital engineers. Life Safety Code 101 Chapter 39 Existing Business occupancies utilized for reference.

180 Kennedy Memorial Drive Complex.

1.Oxygen warning signs not provide at all locations storing medical oxygen ( NFPA 99)
2.Deadbolts observed at 2 interior office exit doors suite 202 .
3.Toaster oven located to close to combustible materials( shelves).

174 Kennedy Memorial Drive Building

1.No handrails provided for exterior ramp.
2.Coat rack obstructing west exit stair enclosure.
3.Building not provided with approved ac/dc illuminated exit signs both levels.
4.Door to medical records storage room does not latch
5.Mechanical room fire door found wedged open.
6.Clothes dryer has non-approved combustible vent hose.
7.Rear exit stairway lower level has combustible storage.

244 Kennedy Memorial Drive.

1. Fire alarm testing documents not available for review.

246 Kennedy Memorial Drive.

1.West exit stair enclosure has combustible storage.

325- D Kennedy Memorial Drive

1. Fire alarm testing documents not available for review.
2. Exit sign main level not illuminated.

10 Washington Street.

1. South exit door has 9 inch drop off outside ground level.
2.Basement stairs not provided with guards.

80 Main Street Unity.

1.Handrails not provided at employee entrance.
2.Vault door is obstructing the required 44 inch corridor width.
3.Boiler room ceiling and walls have unprotected penetrations.
4.The 1 hour fire rated door to old basement does not have the glazing installed.
5.The old employee entrance/exit has a drop off that exceeds 1/2 inch.

121 Main Street Fairfield New Horizons.

1.Boiler room ceiling,walls,and door is not 1 hour fire rated.
2.Clothes dryer in boiler room has combustible type vent hose.
3.There is combustible storage around the hot air furnace.
4.The chimney is not fire stopped at the floor. ( NFPA 211)
5.Oxygen bottles in basement storage room not secured ( NFPA 99)
6.Storage room door basement does not have a latching device.
7.Basement stairs west side does not have approved gaurds.
8.Door at the top of both basement stairs are not 1 hour fire rated.

K-145 Not Met.
Findings: The type I EES generator does not have remote monitoring of the status of the EES. Reference NFPA 110 1999 Edition section 3-5.6.1
Hospital engineer acknowledged this condition.

K-17 Not Met.
Findings. Door to storage room medical surgical wing is not latching as required.This condition observed and identified to hospital engineer by Inspector.

K-20 Not Met.
Findings: the fire door at the top of west exit stair to corridor( Med Surg wing) is not properly self-closing or latching. This condition observed by Inspector and identified to Hospital engineer.

K-29 Not Met.
Findings: Soiled utility rooms not properly protected as required ( 2 Locations)
a. Door to soiled utility room basement level has an approximately 3/4 inch gap at the door frame side.
b. Doors(2) soiled utility room Med Surg Wing are not provided with latching devices.
This condition observed by Inspector and identified to Hospital engineer.

K-38 Not Met.
Findings: The entrance from west exit stair to MRI area had a 3 inch step up to the ramp serving the MRI trailer that created a potential tripping hazard and exceeded the 1/2 inch allowable change in elevation of walking surfaces in a means of egress.
This condition observed by Inspector and identified to the Hospital engineer.

K-48 Not Met.
Findings: A written copy of the facilities emergency fire and evacuation plan was not available to supervisory personnel in the Cardiac Care Unit.
Inspector asked for a copy of the plan and employees were unable to locate it.
This condition was acknowledged by the Hospital engineer.

K-61 Not Met
Findings: While reviewing the facilities maintenance records Inspector observed the sprinkler companies reports and found that the service technician recorded that the sprinkler tamper switch was not working on 3 of 4 quarterly reports and at the time of this inspection this condition has not been corrected.
The Hospital Administrator was made aware of the condition at a meeting 3/2/2010 1630 hrs.

K-62 Not Met.
Findings: While reviewing the facilities maintenance records Inspector observed that the sprinkler service report indicated that the outside sprinkler warning bell was not functioning on more than 1 quarterly report. This condition at the time of the inspection has not been corrected.
The Hospital Administrator was made aware of the condition at a meeting 3.2/2010 1630 Hrs.

K-69 Not Met.
Findings: Cafeteria and main kitchen cooking equipment ( fry-olators) are positioned less than 18 inches from grills and sources of ignition that can produce vapor laden grease fires. NFPA 96 section 9.1.2.3.
This condition acknowledged by the Hospital engineer.

Findings: The hood in the cafeteria does not have an approved grease collection cup for the filter channel.

Findings: The gas piping and areas behind the cooking equipment have considerable grease accumulation.

K-77 Not Met.
Findings: Outside storage of medical oxygen supply shall have gates and enclosures that are capable of being locked. NFPA 99 section 4-3.1.1.2 paragraph 11 item c. The lock on the chain was found unlocked.
Hospital engineer observed and acknowledged this condition.

K-130 Not Met.
Findings: The following deficiencies were observed while surveying the hospital offsite locations with hospital engineers. Life Safety Code 101 Chapter 39 Existing Business occupancies utilized for reference.

180 Kennedy Memorial Drive Complex.

1.Oxygen warning signs not provide at all locations storing medical oxygen ( NFPA 99)
2.Deadbolts observed at 2 interior office exit doors suite 202 .
3.Toaster oven located to close to combustible materials( shelves).

174 Kennedy Memorial Drive Building

1.No handrails provided for exterior ramp.
2.Coat rack obstructing west exit stair enclosure.
3.Building not provided with approved ac/dc illuminated exit signs both levels.
4.Door to medical records storage room does not latch
5.Mechanical room fire door found wedged open.
6.Clothes dryer has non-approved combustible vent hose.
7.Rear exit stairway lower level has combustible storage.

244 Kennedy Memorial Drive.

1. Fire alarm testing documents not available for review.

246 Kennedy Memorial Drive.

1.West exit stair enclosure has combustible storage.

325- D Kennedy Memorial Drive

1. Fire alarm testing documents not available for review.
2. Exit sign main level not illuminated.

10 Washington Street.

1. South exit door has 9 inch drop off outside ground level.
2.Basement stairs not provided with guards.

80 Main Street Unity.

1.Handrails not provided at employee entrance.
2.Vault door is obstructing the required 44 inch corridor width.
3.Boiler room ceiling and walls have unprotected penetrations.
4.The 1 hour fire rated door to old basement does not have the glazing installed.
5.The old employee entrance/exit has a drop off that exceeds 1/2 inch.

121 Main Street Fairfield New Horizons.

1.Boiler room ceiling,walls,and door is not 1 hour fire rated.
2.Clothes dryer in boiler room has combustible type vent hose.
3.There is combustible storage around the hot air furnace.
4.The chimney is not fire stopped at the floor. ( NFPA 211)
5.Oxygen bottles in basement storage room not secured ( NFPA 99)
6.Storage room door basement does not have a latching device.
7.Basement stairs west side does not have approved gaurds.
8.Door at the top of both basement stairs are not 1 hour fire rated.

K-145 Not Met.
Findings: The type I EES generator does not have remote monitoring of the status of the EES. Reference NFPA 110 1999 Edition section 3-5.6.1
Hospital engineer acknowledged this condition.