HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer
it was observed that the facility failed to provide a log indicating compliance on FLAME SPREAD RATINGS for interior finishes on surfaces other than concrete, plaster, or gypsum board at Corridor / Lobby floors, walls, and ceilings.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer it was observed that the DRY FOOD STORAGE ROOM in the Dietary Department did not comply with the following 1 hour fire-resistive construction requirements for this room:

1. Did not have 1 hour fire-rated partition construction.
2. Did not have 45 minute fire-rated door assembly (door, door frame, door hardware).
3. Did not have self-closing door.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response. Additionally, while it appeared that the facility had accomplished yearly inspections, their documentation was incomplete, and not logged in a systematic fashion.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer it was observed that the facility failed to provide a log indicating compliance on FLAME RETARDANT PROPERTIES of drapes, curtains, including cubicle curtains, mattresses and upholstered furniture.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer it was observed that the facility failed to provide a log indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Additionally, at several randomly selected partition locations:
3. It was observed that the facility's system of 1 hour fire and smoke rated partitions separating the various Smoke Compartments had multiple types and locations of unsealed penetrations. The integrity of these fire and smoke rated partitions had been violated. As a result of these typical findings, it was concluded that the entire network of fire and smoke rated partitions intended to provide protection be completely surveyed and any and all unsealed penetrations be identified and brought into compliance with NFPA requirements.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer
it was observed that the facility failed to provide a log indicating compliance on FLAME SPREAD RATINGS for interior finishes on surfaces other than concrete, plaster, or gypsum board at Corridor / Lobby floors, walls, and ceilings.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer it was observed that the DRY FOOD STORAGE ROOM in the Dietary Department did not comply with the following 1 hour fire-resistive construction requirements for this room:

1. Did not have 1 hour fire-rated partition construction.
2. Did not have 45 minute fire-rated door assembly (door, door frame, door hardware).
3. Did not have self-closing door.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response. Additionally, while it appeared that the facility had accomplished yearly inspections, their documentation was incomplete, and not logged in a systematic fashion.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer it was observed that the facility failed to provide a log indicating compliance on FLAME RETARDANT PROPERTIES of drapes, curtains, including cubicle curtains, mattresses and upholstered furniture.

Based on observations made during the survey of the facility between the hours of 12:00 pm and 6:00 pm, while accompanied by the CEO, CFO, Director Of Nursing, Sr. Administrative Asst., Director Of Plant Ops, Safety Officer, Past Safety Officer it was observed that the facility failed to provide a log indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Additionally, at several randomly selected partition locations:
3. It was observed that the facility's system of 1 hour fire and smoke rated partitions separating the various Smoke Compartments had multiple types and locations of unsealed penetrations. The integrity of these fire and smoke rated partitions had been violated. As a result of these typical findings, it was concluded that the entire network of fire and smoke rated partitions intended to provide protection be completely surveyed and any and all unsealed penetrations be identified and brought into compliance with NFPA requirements.