HospitalInspections.org

Based on observation and interview, the provider failed to maintain the fire-resistive design of two of two building separation walls (eastern two-hour wall separating the hospital and the clinic). Findings include:

1. Observation on 9/27/22 at 3:28 p.m. revealed the two-hour fire-rated separation wall between the northern hospital wing and the clinic had four layers of 5/8 inch gypsum board on the wall above the lay-in ceiling. The gypsum board had unsealed openings around penetrations by several communication cables.
Those openings were not sealed or provided with any approved material to maintain the fire rating of the wall.

Interview with the maintenance director at the same time confirmed that finding.

The deficiency could affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to ensure adequate illumination of means of egress was provided at one randomly observed exit stair tower (east wing second floor exit). Findings include:

1. Observation on 9/27/22 at 1:25 p.m. revealed the stair tower out of the second floor of the east wing corridor was missing lighting. The lower level of that stair tower had a provision for a light fiture but was not provided with one. Lighting shall be provided such that minimum lighting is still provided in the event a single lighting source is lost. That lighting shall also be capable of providing one and one-half hours of emergency lighting upon loss of normal power.

Interview with the maintenance director at the time of the above observation confirmed that condition. He was not aware that exit discharge was not in compliance with the minimum lighting requirements.

This deficiency has the ability to affect one of seven smoke compartments.

Based on observation and interview, the provider failed to install exit signs for one randomly observed location (vestibule leading to the old therapy addition). Findings include:

1. Observation on 9/27/22 at 1:09 a.m. revealed an exit sign was not present inside the vestibule of the orginal building leading to the old therapy addition. That vestibule had more than one door leaving but only one lead to a qualifying exit. That condition could lead to confusion during an emergency.

Interview with the director of maintenance at the time of the observations confirmed those findings.

The deficiency affected one location required to be provided with a marked and identifiable path of egress.

Based on observation, testing, and interview, the provider failed to maintain one randomly observed hazardous area (laundry room) as required. Findings include:

1. Observation on 9/27/22 at 2:10 p.m. revealed the laundry room was over 100 square feet and contained combustible items. Testing at the same time of the observation revealed the double doors leading to the east corridor did not close and latch into the frame under the power of the automatic door closers. Those doors are required to latch to maintain the fire-rated separation of that room.

Interview with the director of maintenance at the time of the observation confirmed that finding.

The deficiency affected one of numerous requirements for hazardous rooms.

Based on document review and interview, the provider failed to conduct the required every six-month inspections of the cooking facility's fire suppression system for the range hood. Findings include:

1. Document review on 9/27/22 at 11:58 a.m. of the kitchen hood fire suppression system records indicated the only inspection in 2022 had been performed on 8/30/22. The kitchen hood fire-suppression system must be inspected not less than every six months. There was no further documentation indicating any other required inspections had taken place.

Interview with the director of maintenance at that same time confirmed that finding. He stated he was unaware of the requirement to have the hood inspected every six months.

This deficiency affected one of numerous kitchen hood fire suppression system requirements.

Based on observation, interview, and document review, the provider failed to perform annual load testing of the generator as required. Findings include:

1. Observation, interview, and document review on 9/27/22 at 2:46 p.m. revealed no records could be provided that showed the diesel fired 310KW Caterpillar generator was ran loaded monthly at a minimum of 30 percent or received an annual load test. Diesel-fired generators providing back-up power to the emergency power supply system is required to be ran under load monthly at a minimum of 30% or have an annual load test.

Interview with the director of maintenance at that same time confirmed that finding.

This deficiency has the potential to affect 100% of the occupants of the building.