HospitalInspections.org

K-223
Based on staff interviews, record review and observations during the facility survey on June 11, 2019, it was determined that the facility failed to meet the life safety protection requirements of the Life Safety Code (NFPA 101) by not maintaining self-closing doors.

This was evidenced by:

1) Self-closing door from Cardio area to corridor did not latch.
2) Self closing door devise required on maintenance shop doors.to corridor.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within 2 of 5 of the smoke compartments. Deficient items were discussed with the Facilities Director during the survey and again with the Facilities Director, CEO and the Quality Committee (8 people) of the hospital during the exit conference.

K-324
Based on staff interviews, record review and observations during the facility survey on June 11, 2019, it was determined that the facility failed to meet the life safety protection requirements of NFPA 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations) 12.1.2.3.1-An approved method shall be provided that will ensure that the appliance is returned to an approved design location.

This was evidenced by:

1) There was no method (wheel chocks, restraints) on all wheel equipped cooking appliances under two kitchen hoods to return/verify that the alignment of each appliance was correct.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within 1 of 5 of the smoke compartments. Deficient items were discussed with the Facilities Director during the survey and again with the Facilities Director, CEO and the Quality Committee (8 people) of the hospital during the exit conference.

K-353
Based on staff interviews, record review and observations during the facility survey on June 11, 2019, it was determined that the facility failed to meet the life safety protection requirements of the Life Safety Code (NFPA 101) ,the Standard for Installation of Sprinkler Systems (NFPA 13) and the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (NFPA 25) by not maintaining the fire sprinkler system.

This was evidenced by:

1) Walk-in cooler sprinkler head loaded with dust/debris.
2) Gauges on riser are out of date (2011). - Must be replaced/recalibrated every 5 years.
3) Spare sprinkler heads (5) lacking in box by riser. 300 sprinklers or less = no fewer than 6/300-1000 sprinklers = no fewer than 12 (NFPA 13 - 6.2.9.5)
4) Multiple storage areas have storage within 18 inches of sprinkler deflector. The clearance between the deflector and the top of storage shall be 18 inches (457 mm) or greater. (NFPA 13 - 8.6.6)
5) Obstruction greater than 4 feet (bubble wrap "wheel") blocking sprinkler spray pattern on Material Storage cage.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within 4 of 5 of the smoke compartments. Deficient items were discussed with the Facilities Director during the survey and again with the Facilities Director, CEO and the Quality Committee (8 people) of the hospital during the exit conference.

K-372
Based on staff interviews, record review and observations during the facility survey on June 11, 2019, it was determined that the facility failed to meet the life safety protection requirements of the Life Safety Code 101 Section 19.3.7.3 by not maintaining smoke barriers.

This was evidenced by the following:

1) Medical gas room has a ceiling penetration in rear corner.
2) Employee hallway by main electrical room (above ceiling grid) has two wall penetrations.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within 2 of 5 of the smoke compartments. Deficient items were discussed with the Facilities Director during the survey and again with the Facilities Director, CEO and the Quality Committee (8 people) of the hospital during the exit conference.

K-781
Based on staff interviews, record review and observations during the facility survey on June 11, 2019, it was determined that the facility failed to meet the life safety protection requirements of the Life Safety Code 101 Section 19.7.8 by using space heaters that have heating elements that do not exceed 212 degrees F.

This was evidenced by:

1) Space heaters in:
CEO Office
VIP Office
PBX Room
Preoperative Area
Patient Admin
Medical Records
Clinic 1

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within 4 of 5 of the smoke compartments. Deficient items were discussed with the Facilities Director during the survey and again with the Facilities Director, CEO and the Quality Committee (8 people) of the hospital during the exit conference.

K-920
Based on staff interviews, record review and observations during the facility survey on June 11, 2019, it was determined that the facility failed to meet the life safety protection requirements of NFPA 70 - the National Electric Code (section 400.8 (1)) by not maintaining safe and accepted wiring within the facility.

This was evidenced by the following:

1) The facility is utilizing a power strip as a substitute for fixed wiring to supply power to a refrigerators and/or microwaves in:
I.T. Systems office (2nd floor)
large Cardio area

2) Multi-plug adapters (without power breaker) in use in:
"Wold's" office
Gift shop

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within 3 of 5 of the smoke compartments. Deficient items were discussed with the Facilities Director during the survey and again with the Facilities Director, CEO and the Quality Committee (8 people) of the hospital during the exit conference.

K-929
Based on staff interviews, record review and observations during the facility survey on June 11, 2019, it was determined that the facility failed to meet the life safety protection requirements of the Health Care Facilities Code (NFPA 99, Section 11.6.2.3(11)) by not protecting oxygen cylinders from damage.

This was evidenced by the following:

1) Medical gas cylinder in room 231was not restrained or secured.

These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within 1 of 5 of the smoke compartments. Deficient items were discussed with the Facilities Director during the survey and again with the Facilities Director, CEO and the Quality Committee (8 people) of the hospital during the exit conference.