HospitalInspections.org

Based on observations, the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 10:30 AM and 1:30 PM on 6/17/10, it was observed that the Boiler Room had a penetration above the door leading to the corridor that had not been sealed with approved through penetration assemblies.

This was confirmed by the Facility's Manager (TH).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow fire development that would reduce the egress conditions affecting all patients, staff and visitors of the facility.

Findings include:

On facility tour between 10:30 AM and 1:30 PM on 6/17/09, it was observed that when the nursery was remolded the room was divided into two potions by a dividing wall. The dividing wall blocks the fire sprinkler coverage from protecting the entry side portions of the remodeled nursery.


This was confirmed by the Facility's Manager (TH).

Based on observations the facility failed to keep the means of egress continuous and free of all obstructions or impediments to full instant use in the case of fire or other emergency, in accordance with NFPA Life Safety Code 101 (2000 edition) Chapter 7, Section 7.1.10. These obstructions could interfere with the convenient and effective removal patients, staff and visitors in an emergency situation, and impede fire fighting operations during a fire emergency.


Findings include:

On facility tour between 10:30 AM and 1:30 PM on 6/17/10, it was observed that a couch in the exit access corridor leading to the northwest exit of the facility was obstructed and that the corridor width was also reduced to below the minimum required 8 feet.


This was confirmed by the Facility's Manager (TH).

Based on observations, the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 10:30 AM and 1:30 PM on 6/17/10, it was observed that the Boiler Room had a penetration above the door leading to the corridor that had not been sealed with approved through penetration assemblies.

This was confirmed by the Facility's Manager (TH).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow fire development that would reduce the egress conditions affecting all patients, staff and visitors of the facility.

Findings include:

On facility tour between 10:30 AM and 1:30 PM on 6/17/09, it was observed that when the nursery was remolded the room was divided into two potions by a dividing wall. The dividing wall blocks the fire sprinkler coverage from protecting the entry side portions of the remodeled nursery.


This was confirmed by the Facility's Manager (TH).

Based on observations the facility failed to keep the means of egress continuous and free of all obstructions or impediments to full instant use in the case of fire or other emergency, in accordance with NFPA Life Safety Code 101 (2000 edition) Chapter 7, Section 7.1.10. These obstructions could interfere with the convenient and effective removal patients, staff and visitors in an emergency situation, and impede fire fighting operations during a fire emergency.


Findings include:

On facility tour between 10:30 AM and 1:30 PM on 6/17/10, it was observed that a couch in the exit access corridor leading to the northwest exit of the facility was obstructed and that the corridor width was also reduced to below the minimum required 8 feet.


This was confirmed by the Facility's Manager (TH).