HospitalInspections.org

Based on observation and document review, the provider failed to meet the minimum construction standards of health care occupancies. Findings include:

1. Observation at 10:00 a.m. revealed the building was a single story, slab on grade building, constructed of heavy timber, Type IV (2HH) in the patient wings and protected noncombustible, Type II (111) in the core area. The core of the building had a partial basement. The building did not have a complete automatic sprinkler system. Review of previous survey records at the time of the observation confirmed that finding.

The building will meet the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain the one hour fire resistive rating of corridor wall assemblies for the recovery suite. The door from the recovery suite to the corridor would not positively latch into the frame. Findings include:

1. Observation at 10:15 a.m. revealed the 1 3/4 inch solid bonded wood door from the recovery suite (room 128) to the corridor would not latch. Interview with the maintenance director at the time of the observation revealed positive latching hardware was recently installed. The hole cut into the hollow metal frame to receive the door bolt was not large enough to allow latching.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The corridor doors to the laundry/soiled linen room would not positively latch. Findings include:

1. Observation at 11:30 a.m. revealed the inactive leaf of the double-door leading from the corridor to the laundry/soiled linen room would not latch into the frame. Interview with the maintenance director at the time of the observation revealed the gap between the two doors would not depress the automatic deadbolt sufficient to allow activation. He indicated he thought the doors were working properly during the monthly door inspection.

Based on observation and interview, the provider failed to maintain the two hour fire resistive separation of the horizontal exit between the health care and business occupancies. Two of three sets of three hour fire resistive door assemblies did not meet the required fire resistive separation criteria. Findings include:

1. Observation at 11:30 a.m. revealed the door between the serving area and the kitchen would not automatically close. Interview with the maintenance director at the time of the observation revealed the closer arm had been removed to allow the door to remain in the open position. Staff had disabled the closer to allow easier access during meals. It was discussed that by installing a magnetic hold open device connected to the fire alarm system, the door could be held open when necessary.

2. Observation at 12:00 noon revealed the north leaf of the double egress cross-corridor doors between the hospital and wellness center would not latch when allowed to operate with the door closer. Interview with the maintenance director at the time of the observation confirmed that finding. He indicated the door was operating properly during the most recent monthly inspection of the door. The door was adjusted and operating properly prior to completion of this survey.

Based on observation and review of previous survey documents, the provider failed to maintain two acceptable exits from the basement level of the building. Findings include:

1. Observation at 11:00 a.m. revealed the basement level of the facility did not have conforming exits. Both interior stairs from the basement discharged into the corridor on the first floor level, and there was not a one hour fire rated exit passageway to the exterior of the building. Review of previous survey records at the time of the observation confirmed that finding.

The building will meet the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and record review, the provider failed to maintain clear door widths of at least 32 inches for ten randomly observed sets of exit access doors. Findings include:

1. Observation from 10:00 a.m. until 2:00 p.m. revealed the following doors/leaves were only 30 inches wide and provided less than 32 inches of clear open width:
*The double-doors (each leaf) for the main entrance/exit.
*The double-doors (each leaf) for the entrance vestibule.
*The corridor double-doors (each leaf) from the lobby to the vestibule.
*The doctors' locker room corridor door.
*The south door to the scope room in the north patient wing.
*The nurses' locker room corridor door in the south patient wing west.
*The doctors' changing room (adjacent to surgery) door in the east-west corridor.
*The nurses' changing room door.
*The double-doors (each leaf) to the corridor on the south side of the kitchen.
*The central sterilizing room corridor double-doors (each leaf).

Review of previous survey records at the time of the above observations confirmed the above findings.

The building will meet the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and document review, the provider failed to meet the minimum construction standards of health care occupancies. Findings include:

1. Observation at 10:00 a.m. revealed the building was a single story, slab on grade building, constructed of heavy timber, Type IV (2HH), in the patient wings and protected noncombustible Type II (111) in the core area. The core of the building had a partial basement. The building did not have a complete automatic sprinkler system. Review of previous survey records at the time of the observation confirmed that finding.

The building will meet the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and document review, the provider failed to meet the minimum construction standards of health care occupancies. Findings include:

1. Observation at 10:00 a.m. revealed the building was a single story, slab on grade building, constructed of heavy timber, Type IV (2HH) in the patient wings and protected noncombustible, Type II (111) in the core area. The core of the building had a partial basement. The building did not have a complete automatic sprinkler system. Review of previous survey records at the time of the observation confirmed that finding.

The building will meet the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain the one hour fire resistive rating of corridor wall assemblies for the recovery suite. The door from the recovery suite to the corridor would not positively latch into the frame. Findings include:

1. Observation at 10:15 a.m. revealed the 1 3/4 inch solid bonded wood door from the recovery suite (room 128) to the corridor would not latch. Interview with the maintenance director at the time of the observation revealed positive latching hardware was recently installed. The hole cut into the hollow metal frame to receive the door bolt was not large enough to allow latching.

Based on observation and interview, the provider failed to maintain proper separation of hazardous areas. The corridor doors to the laundry/soiled linen room would not positively latch. Findings include:

1. Observation at 11:30 a.m. revealed the inactive leaf of the double-door leading from the corridor to the laundry/soiled linen room would not latch into the frame. Interview with the maintenance director at the time of the observation revealed the gap between the two doors would not depress the automatic deadbolt sufficient to allow activation. He indicated he thought the doors were working properly during the monthly door inspection.

Based on observation and interview, the provider failed to maintain the two hour fire resistive separation of the horizontal exit between the health care and business occupancies. Two of three sets of three hour fire resistive door assemblies did not meet the required fire resistive separation criteria. Findings include:

1. Observation at 11:30 a.m. revealed the door between the serving area and the kitchen would not automatically close. Interview with the maintenance director at the time of the observation revealed the closer arm had been removed to allow the door to remain in the open position. Staff had disabled the closer to allow easier access during meals. It was discussed that by installing a magnetic hold open device connected to the fire alarm system, the door could be held open when necessary.

2. Observation at 12:00 noon revealed the north leaf of the double egress cross-corridor doors between the hospital and wellness center would not latch when allowed to operate with the door closer. Interview with the maintenance director at the time of the observation confirmed that finding. He indicated the door was operating properly during the most recent monthly inspection of the door. The door was adjusted and operating properly prior to completion of this survey.

Based on observation and review of previous survey documents, the provider failed to maintain two acceptable exits from the basement level of the building. Findings include:

1. Observation at 11:00 a.m. revealed the basement level of the facility did not have conforming exits. Both interior stairs from the basement discharged into the corridor on the first floor level, and there was not a one hour fire rated exit passageway to the exterior of the building. Review of previous survey records at the time of the observation confirmed that finding.

The building will meet the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and record review, the provider failed to maintain clear door widths of at least 32 inches for ten randomly observed sets of exit access doors. Findings include:

1. Observation from 10:00 a.m. until 2:00 p.m. revealed the following doors/leaves were only 30 inches wide and provided less than 32 inches of clear open width:
*The double-doors (each leaf) for the main entrance/exit.
*The double-doors (each leaf) for the entrance vestibule.
*The corridor double-doors (each leaf) from the lobby to the vestibule.
*The doctors' locker room corridor door.
*The south door to the scope room in the north patient wing.
*The nurses' locker room corridor door in the south patient wing west.
*The doctors' changing room (adjacent to surgery) door in the east-west corridor.
*The nurses' changing room door.
*The double-doors (each leaf) to the corridor on the south side of the kitchen.
*The central sterilizing room corridor double-doors (each leaf).

Review of previous survey records at the time of the above observations confirmed the above findings.

The building will meet the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and document review, the provider failed to meet the minimum construction standards of health care occupancies. Findings include:

1. Observation at 10:00 a.m. revealed the building was a single story, slab on grade building, constructed of heavy timber, Type IV (2HH), in the patient wings and protected noncombustible Type II (111) in the core area. The core of the building had a partial basement. The building did not have a complete automatic sprinkler system. Review of previous survey records at the time of the observation confirmed that finding.

The building will meet the FSES. Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.