HospitalInspections.org

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide doors that opened into the corridor which maintained the smoke-tight integrity of the corridor system as evidenced by the following items. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: It was observed at 3:11pm on Monday August 6th with Staff E that the paired doors into the CT suite were not equipped with an astragal to insure a smoke tight door opening. [Second Level /I-2 occupancy]
Item #2: It was observed at 7:29am on Tuesday August 7th with Staff E that the paired doors from the Emergency Department were not equipped with an astragal to insure a smoke tight door opening. [Second Level /I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide smoke compartment walls that were constructed to a 1/2 hourly rating as evidenced by the following items. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: It was observed at 2:12pm on Monday August 6th with Staff E that the west wall of the smoke compartment in the corridor had three (3) pipe penetrations, one (1) broken concrete block and one (1) 2" wide gap at the north end of this wall that were not sealed closed or fire caulked to a 1/2 hourly rating. [First Floor /I-2 occupancy]
Item #2: It was observed at 2:13pm on Monday August 6th with Staff E that the east wall of the smoke compartment in the corridor had four (4) pipe penetrations and one taped and mudded patch that were not sealed closed or fire caulked to a 1/2 hourly rating. [First Floor /I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide smoke doors that met the minimums standards for these openings in a smoke barrier wall as evidenced by the following items. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: It was observed at 3:12pm on Monday August 6th with Staff E the meeting edge of the paired doors at the smoke compartment wall were not covered with an astragal to prevent the passage of smoke. [Second Level /I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not properly enclose hazardous areas with walls that were properly rated and sealed to the minimum standards for these rooms. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: It was observed at 1:12pm on Monday August 6th with Staff E that a former conference room was now being used for a large amount of storage of combustibles and the room was greater than 100 square feet. The door was not labeled at 45 minutes, no door closer was present, and none of the perimeter walls were sealed on both sides at all penetrations to a one-hour rating. The function of this room changed in the last year and must meet new standards for a hazardous area. [First level /I-2 occupancy]
Item #2: It was observed at 1:18pm on Monday August 6th with Staff E that a 6" round polyvinyl chloride (pvc) line penetrated the north wall of the Generator room and was not equipped with a fire collar to maintain the rating of this room. [First level/I-2 occupancy]
Item #3: It was observed at 1:18pm on Monday August 6th with Staff E that a 6" round pvc line penetrated the north wall of the Generator room and was not equipped with a fire collar to maintain the rating of this room. [First level/I-2 occupancy]
Item #4: It was observed at 1:20pm on Monday August 6th with Staff E that one (1) 1" water pipe near the east wall line through the floor and one (1) insulated pipe near the south wall that penetrated the floor of the Generator room #136 were not fire caulked to maintain the rating of this room. [First level/I-2 occupancy]
Item #5: It was observed at 1:24pm on Monday August 6th with Staff E that a 4" round polyvinyl chloride (pvc) line was not equipped with a fire collar to maintain a two-hour rating in the Telephone room. [First level/I-2 occupancy]
Item #6: It was observed at 1:33pm on Monday August 6th with Staff E that six (6) penetrations in the floor deck were only sealed with fiberglass insulation, this did not maintain the rating of this floor. Also three (3) penetrations in the east wall were not fire caulked to maintain the hourly rating of this room. [First level/I-2 occupancy]
Item #7: It was observed at 1:38pm on Monday August 6th with Staff E that a 6" round polyvinyl chloride (pvc) line penetrated the north wall of the Generator room and was not equipped with a fire collar to maintain the rating of this room. [First level/I-2 occupancy]
Item #8: It was observed at 1:42pm on Monday August 6th with Staff E that a six (6) 4" polyvinyl chloride (pvc) lines penetrated the floor above without fire collars, six (6) floor penetrations and abandoned pipe sleeves were not fire caulked inside the pipes/penetrations, and two (2) locations where foam plastic was not covered with a non-combustible material. These conditions did not maintain the hourly rating of Mechanical #112. [First level/I-2 occupancy]
Item #9: It was observed at 7:20am on Tuesday August 7th with Staff E that Clean Utility was a one-hour fire barrier. Twelve (12) penetrations were found in the south wall that were not fire caulked within the room and on the corridor side of this wall to maintain the hourly rating of this room. [Second level/I-2 occupancy]
Item #10: It was observed at 7:29am on Tuesday August 7th with Staff E that Housekeeping #226 was indicated as a one-hour enclosure; the penetrations into these walls were not fire caulked to maintain the hourly rating. [Second level/I-2 occupancy
Item #11: It was observed at 7:33am on Tuesday August 7th with Staff E that none of the walls around Soiled Utility #223 were taped and mudded and some penetrations were not fire caulked to a one-hour rating. [Second level/I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide a level surface on both sides of a door in a means of egress. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1. It was observed at 1:03pm on Monday August 6th with Staff E that the floor level at the exit discharge door from the Northwest stair was not level on both sides of the door. The concrete walk outside has settled and the vertical drop was greater than 1/2". [First Level /I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide a sprinkler system that complied with code minimum standards as evidenced by the following item. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Finding includes:
Item #1. It was observed and noted in an interview with Staff E at 10:08am on Monday August 6th that no sprinkler head was installed within two of the three elevator equipment rooms. No alternate means of fire protection was found within either of these two rooms. The facility is not considered a 'completely protected' building. [Lower Level /I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide doors that opened into the corridor which maintained the smoke-tight integrity of the corridor system as evidenced by the following items. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: It was observed at 3:11pm on Monday August 6th with Staff E that the paired doors into the CT suite were not equipped with an astragal to insure a smoke tight door opening. [Second Level /I-2 occupancy]
Item #2: It was observed at 7:29am on Tuesday August 7th with Staff E that the paired doors from the Emergency Department were not equipped with an astragal to insure a smoke tight door opening. [Second Level /I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide smoke compartment walls that were constructed to a 1/2 hourly rating as evidenced by the following items. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: It was observed at 2:12pm on Monday August 6th with Staff E that the west wall of the smoke compartment in the corridor had three (3) pipe penetrations, one (1) broken concrete block and one (1) 2" wide gap at the north end of this wall that were not sealed closed or fire caulked to a 1/2 hourly rating. [First Floor /I-2 occupancy]
Item #2: It was observed at 2:13pm on Monday August 6th with Staff E that the east wall of the smoke compartment in the corridor had four (4) pipe penetrations and one taped and mudded patch that were not sealed closed or fire caulked to a 1/2 hourly rating. [First Floor /I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide smoke doors that met the minimums standards for these openings in a smoke barrier wall as evidenced by the following items. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: It was observed at 3:12pm on Monday August 6th with Staff E the meeting edge of the paired doors at the smoke compartment wall were not covered with an astragal to prevent the passage of smoke. [Second Level /I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not properly enclose hazardous areas with walls that were properly rated and sealed to the minimum standards for these rooms. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: It was observed at 1:12pm on Monday August 6th with Staff E that a former conference room was now being used for a large amount of storage of combustibles and the room was greater than 100 square feet. The door was not labeled at 45 minutes, no door closer was present, and none of the perimeter walls were sealed on both sides at all penetrations to a one-hour rating. The function of this room changed in the last year and must meet new standards for a hazardous area. [First level /I-2 occupancy]
Item #2: It was observed at 1:18pm on Monday August 6th with Staff E that a 6" round polyvinyl chloride (pvc) line penetrated the north wall of the Generator room and was not equipped with a fire collar to maintain the rating of this room. [First level/I-2 occupancy]
Item #3: It was observed at 1:18pm on Monday August 6th with Staff E that a 6" round pvc line penetrated the north wall of the Generator room and was not equipped with a fire collar to maintain the rating of this room. [First level/I-2 occupancy]
Item #4: It was observed at 1:20pm on Monday August 6th with Staff E that one (1) 1" water pipe near the east wall line through the floor and one (1) insulated pipe near the south wall that penetrated the floor of the Generator room #136 were not fire caulked to maintain the rating of this room. [First level/I-2 occupancy]
Item #5: It was observed at 1:24pm on Monday August 6th with Staff E that a 4" round polyvinyl chloride (pvc) line was not equipped with a fire collar to maintain a two-hour rating in the Telephone room. [First level/I-2 occupancy]
Item #6: It was observed at 1:33pm on Monday August 6th with Staff E that six (6) penetrations in the floor deck were only sealed with fiberglass insulation, this did not maintain the rating of this floor. Also three (3) penetrations in the east wall were not fire caulked to maintain the hourly rating of this room. [First level/I-2 occupancy]
Item #7: It was observed at 1:38pm on Monday August 6th with Staff E that a 6" round polyvinyl chloride (pvc) line penetrated the north wall of the Generator room and was not equipped with a fire collar to maintain the rating of this room. [First level/I-2 occupancy]
Item #8: It was observed at 1:42pm on Monday August 6th with Staff E that a six (6) 4" polyvinyl chloride (pvc) lines penetrated the floor above without fire collars, six (6) floor penetrations and abandoned pipe sleeves were not fire caulked inside the pipes/penetrations, and two (2) locations where foam plastic was not covered with a non-combustible material. These conditions did not maintain the hourly rating of Mechanical #112. [First level/I-2 occupancy]
Item #9: It was observed at 7:20am on Tuesday August 7th with Staff E that Clean Utility was a one-hour fire barrier. Twelve (12) penetrations were found in the south wall that were not fire caulked within the room and on the corridor side of this wall to maintain the hourly rating of this room. [Second level/I-2 occupancy]
Item #10: It was observed at 7:29am on Tuesday August 7th with Staff E that Housekeeping #226 was indicated as a one-hour enclosure; the penetrations into these walls were not fire caulked to maintain the hourly rating. [Second level/I-2 occupancy
Item #11: It was observed at 7:33am on Tuesday August 7th with Staff E that none of the walls around Soiled Utility #223 were taped and mudded and some penetrations were not fire caulked to a one-hour rating. [Second level/I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide a level surface on both sides of a door in a means of egress. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1. It was observed at 1:03pm on Monday August 6th with Staff E that the floor level at the exit discharge door from the Northwest stair was not level on both sides of the door. The concrete walk outside has settled and the vertical drop was greater than 1/2". [First Level /I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide a sprinkler system that complied with code minimum standards as evidenced by the following item. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Finding includes:
Item #1. It was observed and noted in an interview with Staff E at 10:08am on Monday August 6th that no sprinkler head was installed within two of the three elevator equipment rooms. No alternate means of fire protection was found within either of these two rooms. The facility is not considered a 'completely protected' building. [Lower Level /I-2 occupancy]