HospitalInspections.org

Based on observation and interview, the facility failed to maintain the 2 hour fire wall between the facility and the Clinic Building in accordance with Section 19.1.1.4.2 of the 2000 Life Safety Code. This deficient practice would affect approximately all staff and residents within the facility. This facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.
Findings include:

Observation and interview on 11/5/13, revealed a corrugated metal ceiling in the 2 hour fire resistant wall between the hospital and the clinic building located in the Walkway that was not properly separated. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 2 of 7 doors in 1 of 30 smoke zones in proper working condition. This deficient practice would affect approximately 2 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 2nd Floor Podiatrist Office Storage room revealed the door was obstructed from closing with the door closer by a piece of foam.

2. The 2nd Floor Podiatrist Doctor's Office Door revealed the door was obstructed from closing by cables in the doorway.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 of 15 Smoke Barriers free of all penetrations. Smoke barrier walls shall maintain a 30 minute fire resistance rating and shall extend from exterior wall to exterior wall and from the floor to the ceiling. This deficient practice would affect approximately 20 staff members within the facility. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observation and interview on 11/5/13, revealed a cable bundle penetration (approximately 2 inches in size) located in the 1st Floor West Double Doors to the Walkway. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of 16 of approximately 30 hazardous areas in 10 of 30 smoke zones from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents.


Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 1st floor OR Sterilization Room revealed 3 vertical conduit penetrations (approximately 1 inch in size) and a hole (approximately 3 inches in size) located in the ceiling.

2. The 1st Floor Sterile Equipment Back Corridor Entry revealed the corridor door was not equipped with a self-closing device on the door.

3. The 1st Floor Old Boiler Room revealed a wire/CSST penetration (approximately 4 inches in size) and a conduit penetration (approximately 2 inches in size) located in the wall to the Therapy Room.

4. The Community Relations Storage Room revealed 3 holes (approximately 1/2 inch in size) located in the Corridor Door and a hole (approximately 1 inch in size) located in the Corridor Wall.

5. The Community Relations Storage Room revealed the Corridor Door was not equipped with a self-closing device.

6. The Loading Dock to the Corridor revealed a conduit penetration (approximately 1/2 inch in size) and a hole (approximately 1 inch in size) located in the Corridor Wall.

7. The Registration North Office Storage Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

8. The 2nd Floor Fire Panel Room revealed a hole (approximately 2 inches in size) located in the wall.

9. The 2nd Floor South Janitor Closet revealed a conduit penetration (approximately 1/2 inch in size) located in the wall.

10. The Gift Shop Storage Room revealed the door was propped open.

11. The 2nd Floor Supply Room 210 revealed a hole (approximately 1/2 inch in size) located around a sprinkler pipe in the wall.

12. The 2nd Floor Penthouse revealed the Door failed to close and latch properly into the door frame with the swing of the door closer when tested.

13. The Basement Kitchen Large Storage Room revealed 2 conduit penetrations (approximately 1/2 inch in size) located in the ceiling lid.

14. The Basement Kitchen Pantry revealed the door was held open with a wire.

15. The Basement Elevator Equipment Room revealed 2 conduit penetrations (approximately 1/2 inch in size) located in the Corridor Wall.

16. The Mechanical Room/Maintenance Director Office Area revealed the door failed to close and latch properly into the door frame with the swing of the door closer when tested.

17. The Boiler Room revealed the Corridor Door failed to close and latch properly into the door frame with the swing of the door closer.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 8 egress doors in 2 of 30 smoke zones easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect approximately 10 staff members within the affected zones. This facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.
Findings include:
Observations and interview on 11/5/13, revealed the following:
1. The Basement Kitchen Storage Room revealed a bolt/latch lock on the door.
2. The Basement Medical Records Room revealed 7 cages that were equipped with cage doors that required a tight grip, pinch, and twist to open the doors.
The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's Fire Alarm system in 2 of 30 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Code, 1999 edition. This deficient practice would affect approximately 20 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 1st Floor Loading Dock revealed the Fire Alarm Control Panel Electrical Breaker #8 located in Electrical Panel "LB" was not locked out.

2. The 2nd Floor South Janitor Closet revealed the Fire Alarm Control Panel Electrical Breaker was not locked out.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide proper sprinkler coverage in 1 room in 1 of 30 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 13, Installation of Sprinkler System, 1998 edition. This deficient practice would affect approximately 15 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observation and interview on 11/5/13, revealed the facility failed to provide sprinkler coverage in the Purchasing Office Supply Closet. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's sprinkler system in 2 of 30 smoke zones accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect approximately 25 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 1st floor North Employee Entrance Janitor closet revealed IT cables that were completely covering the sprinkler head.

2. The 2nd Floor Serenity Suite Patient Room revealed paint on the sprinkler head in the Bathroom.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide proper documentation for the commercial cooking equipment in accordance with Sections 19.3.2.6 and 9.2.3 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and the NFPA Standard 96, Standard for the Ventilation Control and Fire Protection of Commercial Cooking Operations. This deficient practice would affect all residents within the facility. This facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.
Findings include:

Record review and interview on 11/5/13, revealed the facility failed to provide monthly visual inspections of the Commercial Cooking Equipment Ansul System. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed to provide curtains/drapes/hanging fabrics in 1 of 15 rooms in 1 of 30 smoke zones that were in accordance with Section 10.3.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. Curtains, draperies, and loosely hanging fabrics shall be in accordance with NFPA Standard 701, Standard Methods of Fire tests for Flame Propagation of Textiles and Films. This deficient practice would affect approximately 1 staff member within the affected zone. This facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observation and interview on 11/5/13, revealed a vinyl mini-blind located in the CT Observation Room. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on record review, observation, and interview, the facility failed to provide proper testing and documentation of the building's emergency generator in accordance with the National Fire Protection Association (NFPA) Standard 110, 1999 edition. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Record review, observation, and interview on 11/5/13, revealed the following:

1. The facility failed to provide weekly visual inspections for the building's Emergency Generator.

2. The Basement '78 Addition Mechanical Room revealed there was no emergency lighting unit installed by the Transfer Switch to the Generator.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's electrical system in 15 of 30 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 25 residents and had a census of 7 residents on the date of inspection.

Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 2nd Floor Shell Spare Room revealed a drop cord to a surge protector and a fan plugged into the surge protector.

2. The OR Back Hallway Sterilization Room revealed a broken light switch cover.

3. The Decon Equipment Room revealed a charging station plugged into a surge protector.

4. The Administrative Assistant Area revealed a broken electrical outlet cover.

5. The Electrical Panel "A" revealed Breakers 9, 12, 14, 15, 21, 23, 25, 28, and 29 were not labeled.

6. The Laboratory revealed a storage cart placed in front of the electrical panels.

7. The Gift Shop Storage Room revealed materials stored in front of the electrical panels.

8. The 2nd Floor Genesis Development Reception South revealed a 6-way electrical outlet adapter.

9. The 2nd Floor Genesis Development Reception North revealed a 6-way electrical outlet adapter.

10. The 2nd Floor Genesis Development Support Community Living revealed a lamp plugged into a surge protector.

11. The 2nd Floor Exit by Room 218 revealed open electrical wires in a light located on the exterior of the building.

12. The Maintenance Office revealed two 6-way electrical outlet adapter devices.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain the 2 hour fire wall between the facility and the Clinic Building in accordance with Section 19.1.1.4.2 of the 2000 Life Safety Code. This deficient practice would affect approximately all staff and residents within the facility. This facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.
Findings include:

Observation and interview on 11/5/13, revealed a corrugated metal ceiling in the 2 hour fire resistant wall between the hospital and the clinic building located in the Walkway that was not properly separated. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 2 of 7 doors in 1 of 30 smoke zones in proper working condition. This deficient practice would affect approximately 2 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 2nd Floor Podiatrist Office Storage room revealed the door was obstructed from closing with the door closer by a piece of foam.

2. The 2nd Floor Podiatrist Doctor's Office Door revealed the door was obstructed from closing by cables in the doorway.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 of 15 Smoke Barriers free of all penetrations. Smoke barrier walls shall maintain a 30 minute fire resistance rating and shall extend from exterior wall to exterior wall and from the floor to the ceiling. This deficient practice would affect approximately 20 staff members within the facility. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observation and interview on 11/5/13, revealed a cable bundle penetration (approximately 2 inches in size) located in the 1st Floor West Double Doors to the Walkway. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of 16 of approximately 30 hazardous areas in 10 of 30 smoke zones from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents.


Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 1st floor OR Sterilization Room revealed 3 vertical conduit penetrations (approximately 1 inch in size) and a hole (approximately 3 inches in size) located in the ceiling.

2. The 1st Floor Sterile Equipment Back Corridor Entry revealed the corridor door was not equipped with a self-closing device on the door.

3. The 1st Floor Old Boiler Room revealed a wire/CSST penetration (approximately 4 inches in size) and a conduit penetration (approximately 2 inches in size) located in the wall to the Therapy Room.

4. The Community Relations Storage Room revealed 3 holes (approximately 1/2 inch in size) located in the Corridor Door and a hole (approximately 1 inch in size) located in the Corridor Wall.

5. The Community Relations Storage Room revealed the Corridor Door was not equipped with a self-closing device.

6. The Loading Dock to the Corridor revealed a conduit penetration (approximately 1/2 inch in size) and a hole (approximately 1 inch in size) located in the Corridor Wall.

7. The Registration North Office Storage Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

8. The 2nd Floor Fire Panel Room revealed a hole (approximately 2 inches in size) located in the wall.

9. The 2nd Floor South Janitor Closet revealed a conduit penetration (approximately 1/2 inch in size) located in the wall.

10. The Gift Shop Storage Room revealed the door was propped open.

11. The 2nd Floor Supply Room 210 revealed a hole (approximately 1/2 inch in size) located around a sprinkler pipe in the wall.

12. The 2nd Floor Penthouse revealed the Door failed to close and latch properly into the door frame with the swing of the door closer when tested.

13. The Basement Kitchen Large Storage Room revealed 2 conduit penetrations (approximately 1/2 inch in size) located in the ceiling lid.

14. The Basement Kitchen Pantry revealed the door was held open with a wire.

15. The Basement Elevator Equipment Room revealed 2 conduit penetrations (approximately 1/2 inch in size) located in the Corridor Wall.

16. The Mechanical Room/Maintenance Director Office Area revealed the door failed to close and latch properly into the door frame with the swing of the door closer when tested.

17. The Boiler Room revealed the Corridor Door failed to close and latch properly into the door frame with the swing of the door closer.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain 8 egress doors in 2 of 30 smoke zones easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect approximately 10 staff members within the affected zones. This facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.
Findings include:
Observations and interview on 11/5/13, revealed the following:
1. The Basement Kitchen Storage Room revealed a bolt/latch lock on the door.
2. The Basement Medical Records Room revealed 7 cages that were equipped with cage doors that required a tight grip, pinch, and twist to open the doors.
The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's Fire Alarm system in 2 of 30 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Code, 1999 edition. This deficient practice would affect approximately 20 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 1st Floor Loading Dock revealed the Fire Alarm Control Panel Electrical Breaker #8 located in Electrical Panel "LB" was not locked out.

2. The 2nd Floor South Janitor Closet revealed the Fire Alarm Control Panel Electrical Breaker was not locked out.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide proper sprinkler coverage in 1 room in 1 of 30 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 13, Installation of Sprinkler System, 1998 edition. This deficient practice would affect approximately 15 staff members within the affected zone. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observation and interview on 11/5/13, revealed the facility failed to provide sprinkler coverage in the Purchasing Office Supply Closet. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's sprinkler system in 2 of 30 smoke zones accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect approximately 25 staff members within the affected zones. The facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 1st floor North Employee Entrance Janitor closet revealed IT cables that were completely covering the sprinkler head.

2. The 2nd Floor Serenity Suite Patient Room revealed paint on the sprinkler head in the Bathroom.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide proper documentation for the commercial cooking equipment in accordance with Sections 19.3.2.6 and 9.2.3 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and the NFPA Standard 96, Standard for the Ventilation Control and Fire Protection of Commercial Cooking Operations. This deficient practice would affect all residents within the facility. This facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.
Findings include:

Record review and interview on 11/5/13, revealed the facility failed to provide monthly visual inspections of the Commercial Cooking Equipment Ansul System. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed to provide curtains/drapes/hanging fabrics in 1 of 15 rooms in 1 of 30 smoke zones that were in accordance with Section 10.3.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. Curtains, draperies, and loosely hanging fabrics shall be in accordance with NFPA Standard 701, Standard Methods of Fire tests for Flame Propagation of Textiles and Films. This deficient practice would affect approximately 1 staff member within the affected zone. This facility had a capacity of 25 residents and a census of 7 residents on the date of inspection.

Findings include:

Observation and interview on 11/5/13, revealed a vinyl mini-blind located in the CT Observation Room. The Facility Maintenance Director confirmed this finding on the date of inspection.

Based on record review, observation, and interview, the facility failed to provide proper testing and documentation of the building's emergency generator in accordance with the National Fire Protection Association (NFPA) Standard 110, 1999 edition. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 25 residents and a census of 7 residents.

Findings include:

Record review, observation, and interview on 11/5/13, revealed the following:

1. The facility failed to provide weekly visual inspections for the building's Emergency Generator.

2. The Basement '78 Addition Mechanical Room revealed there was no emergency lighting unit installed by the Transfer Switch to the Generator.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's electrical system in 15 of 30 smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect approximately 7 residents within the affected zones. The facility had a capacity of 25 residents and had a census of 7 residents on the date of inspection.

Findings include:

Observations and interview on 11/5/13, revealed the following:

1. The 2nd Floor Shell Spare Room revealed a drop cord to a surge protector and a fan plugged into the surge protector.

2. The OR Back Hallway Sterilization Room revealed a broken light switch cover.

3. The Decon Equipment Room revealed a charging station plugged into a surge protector.

4. The Administrative Assistant Area revealed a broken electrical outlet cover.

5. The Electrical Panel "A" revealed Breakers 9, 12, 14, 15, 21, 23, 25, 28, and 29 were not labeled.

6. The Laboratory revealed a storage cart placed in front of the electrical panels.

7. The Gift Shop Storage Room revealed materials stored in front of the electrical panels.

8. The 2nd Floor Genesis Development Reception South revealed a 6-way electrical outlet adapter.

9. The 2nd Floor Genesis Development Reception North revealed a 6-way electrical outlet adapter.

10. The 2nd Floor Genesis Development Support Community Living revealed a lamp plugged into a surge protector.

11. The 2nd Floor Exit by Room 218 revealed open electrical wires in a light located on the exterior of the building.

12. The Maintenance Office revealed two 6-way electrical outlet adapter devices.

The Facility Maintenance Director confirmed these findings on the date of inspection.