HospitalInspections.org

Based on observations the facility failed to provide the required ½ hour fire resistance rating for smoke barrier walls. This condition has the potential to affect about 100% of the patients and staff.

Findings include:

While inspecting smoke barrier walls on January 19, 2011 at approximately 1:30 p.m., the surveyor observed the smoke barrier wall had the following penetrations:
1. The adult west smoke barrier wall was not sealed to the deck above. There was approximately a two (2) inch gap at the top of the wall.
2. The adolescent girls wing smoke barrier wall was not sealed to the deck above. There was approximately a two (2) inch gap at the top of the wall.
3. Smoke barrier walls had penetrations throughout the facility.

This deficient practice has the potential of affecting three (3) of three (3) smoke compartments. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to properly protect hazardous areas. This deficient practice has the potential of affecting three (3) of three (3) smoke compartments.

Findings include:
On January 19, 2011 at approximately 11:00 a.m., the surveyor and maintenance staff observed the following penetrations in hazardous areas in the facility:
1. All mechanical rooms had penetrations throughout the walls
2. Soiled linen room in the adult West Wing had penetration.
3. Soiled linen room in the adult East Wing had penetration.

The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. This condition affected 100% of the residents and staff as all smoke compartments were affected. NFPA 72 Section 1-5.6

Findings include:
On January 19, 2011 at approximately 11:45 a.m., the surveyor and maintenance staff observed that the location of the automatic dialer lacked a hard wired smoke detector.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building. This condition affected 100% of the patients and staff of the building.

Findings include:
On January 19, 2011 at approximately 10:45 a.m., the surveyor and maintenance staff observed the following deficiencies with the sprinkler system:
1. The sprinkler head above the dialer was only about a 1/4 inch off the wall.
2. The inspector test drain does not have a 1/2 inch reducer installed.

The Administrator and the Maintenance Director were notified during the survey as well as the exit conference.

Based on observations and interviews, the facility failed to properly protect all of the generator's required components. This deficiency had the potential to effect 100% of the patients and staff.

Findings include:
On January 19, 2011 at approximately 11:30 a.m., the surveyor and maintenance staff observed that the facility lacked a task illumination light at the generator. An interview with maintenance staff at this time revealed that the facility was unaware of the requirement.

The Administrator and the Maintenance Director were notified during the survey as well as the exit conference.

Based on observations the facility failed to provide the required ½ hour fire resistance rating for smoke barrier walls. This condition has the potential to affect about 100% of the patients and staff.

Findings include:

While inspecting smoke barrier walls on January 19, 2011 at approximately 1:30 p.m., the surveyor observed the smoke barrier wall had the following penetrations:
1. The adult west smoke barrier wall was not sealed to the deck above. There was approximately a two (2) inch gap at the top of the wall.
2. The adolescent girls wing smoke barrier wall was not sealed to the deck above. There was approximately a two (2) inch gap at the top of the wall.
3. Smoke barrier walls had penetrations throughout the facility.

This deficient practice has the potential of affecting three (3) of three (3) smoke compartments. The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to properly protect hazardous areas. This deficient practice has the potential of affecting three (3) of three (3) smoke compartments.

Findings include:
On January 19, 2011 at approximately 11:00 a.m., the surveyor and maintenance staff observed the following penetrations in hazardous areas in the facility:
1. All mechanical rooms had penetrations throughout the walls
2. Soiled linen room in the adult West Wing had penetration.
3. Soiled linen room in the adult East Wing had penetration.

The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide a properly tested and maintained fire alarm system. This condition affected 100% of the residents and staff as all smoke compartments were affected. NFPA 72 Section 1-5.6

Findings include:
On January 19, 2011 at approximately 11:45 a.m., the surveyor and maintenance staff observed that the location of the automatic dialer lacked a hard wired smoke detector.

The Maintenance Supervisor and the Administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building. This condition affected 100% of the patients and staff of the building.

Findings include:
On January 19, 2011 at approximately 10:45 a.m., the surveyor and maintenance staff observed the following deficiencies with the sprinkler system:
1. The sprinkler head above the dialer was only about a 1/4 inch off the wall.
2. The inspector test drain does not have a 1/2 inch reducer installed.

The Administrator and the Maintenance Director were notified during the survey as well as the exit conference.

Based on observations and interviews, the facility failed to properly protect all of the generator's required components. This deficiency had the potential to effect 100% of the patients and staff.

Findings include:
On January 19, 2011 at approximately 11:30 a.m., the surveyor and maintenance staff observed that the facility lacked a task illumination light at the generator. An interview with maintenance staff at this time revealed that the facility was unaware of the requirement.

The Administrator and the Maintenance Director were notified during the survey as well as the exit conference.