HospitalInspections.org

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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.1, 7.2.1.5.1, 7.2.1.5.3, and 7.1.10.1

This deficiency affects 1 of 6 smoke compartments.

Findings include:

On 02/08/2022, during a tour of the facility from 2:00 pm to 4:00 pm, the surveyor observed the following:
1. A keyed deadbolt lock on the corridor side of the Administration Storage Room (100 sq. ft.) with no means to unlock the mechanism on the room (egress) side.
2. The Clinic Employee exit discharge failed to provide a direct and unobstructed access to public way, parked cars were blocking the access.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a horizontal exit per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects 2 of 6 smoke compartments.

Findings include:

On 02/09/2022, during a tour of the facility from 8:30 am to 4:00 pm, the surveyor observed an unsealed 3/4" conduit used as a sleeve for multiple white cables in the 3 hour fire barrier above the ceiling over the fire barrier cross corridor doors of the OR/OB corridor on the 2nd floor.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain vertical openings per the requirements of:

2012 NFPA 101, 19.3.1, 8.6.3 (1), and 8.3.5.1

This deficiency affects 2 of 6 smoke compartments.

Findings include:

On 02/10/2022, during a tour of the facility from 7:30 am to 2:00 pm, the surveyor observed two unsealed 2" conduits used as sleeves with multiple blue, black and gray cables penetrating the floor/ceiling assembly between the 2nd floor OB Telephone Closet and the 1st floor.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the one-hour fire resistance rating of the elevator shaft per the requirements of:

2012 NFPA 101, 19.3.1.1

This deficiency affects 1 of 6 smoke compartments.

Findings include:

On 02/09/2022, during a tour of the facility from 8:30 am to 4:00 pm, the surveyor observed three, unsealed 2" conduit penetrations of the Wing 1 elevator shaft on the 1st Floor. These penetrations are located between the elevator shaft and the elevator equipment room.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the automatic locking system on the egress corridor exit doors per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 21.9

This deficiency affects 1 of 6 smoke compartments.

Findings include:

On 02/10/2022, during a tour of the facility from 7:30 am to 2:00 pm, the surveyor observed OB's three full time locked egress doors leading to the egress corridor failed to automatically unlock upon loss of power to the fire alarm system.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.10, and 19.3.6.3.5

This deficiency affects 2 of 6 smoke compartments.

Findings include:

On 02/08/2022, during a tour of the facility from 2:00 pm to 4:00 pm, the surveyor observed the following:
1. The corridor doors of Radiology Rooms 1 & 2 were impeded from closing by hold-open devices attached to the doors
2. The two corridor doors for the Hospice Care Office did not have positive latching hardware

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the designated smoking area per the requirements of:

2012 NFPA 101, 19.7.4 (6)

This deficiency affects 1 of 1 designated smoking areas.

Findings include:

On 02/09/2022, during a tour of the facility from 8:00 am to 4:00 pm, the surveyor observed the designated smoking area outside the Administration Wing 1, did not have a metal container with self-closing cover device.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 of 6 smoke compartments.

Findings include:

On 02/10/2022, during a tour of the facility from 7:30 am to 2:00 pm, the surveyor observed a portable space heating device that was turned on and located under a desk on carpet in the Registration Manager's Office. This was not located in a patient sleeping smoke compartment. The facility was unable to provide documentation that the heating element did not exceed 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

This deficiency affects 1 of 6 smoke compartments.

Findings include:

On 02/09/2022, during a tour of the facility from 8:30 am to 4:00 pm, the surveyor observed 6 large M-250 oxygen cylinders not individually secured in the Old ER Patient Room.

A member of the maintenance staff was present when this deficiency was identified.