HospitalInspections.org

Based on observation and interview, the facility does not ensure that all doors in the exit passageway close completely.

Findings include:

Observation during facility tour on 6/10/15 revealed:
- The door at grade level in stairwell "A", which leads to the outside, had the self-closer arm removed. The door was not self-closing.
- When viewing the double doors in the corridor near room #1113 with the main entrance at one's back, with the leaf on the right side, it was observed that the top of the door hits the header, preventing full closure of door by approximately two inches. The door when in the closed position requires a great amount of force to open, as the top of the door wedges into the header.

These findings were verified with Patient Data Manager Staff #2 on 6/10/15.

Based on document review and interview, the facility does not ensure that smoke head sensivity testing is performed, as evidenced for 2009 through 2015.

Findings include:

Review on 6/10/15 of Simplex Grinnell fire alarm system testing reports revealed reports dated: 11/2009, 5/2010, 11/2010, 5/2011, 11/2011, 5/2012, 11/2012, 5/2013, 11/2013, 5/2014, 11/2014 and 5/8/15. There was no evidence in the reports that smoke head sensitivity testing was performed.

This finding was verified by Patient Services Manager Staff #3 on 6/10/15.

Based on document review and interview, the facility does not maintain the sprinkler system as evidenced by the lack of addressing deficiencies noted on the inspector's reports.

Findings include:

Review on 6/10/15 of two facility-provided sprinkler reports, dated 4/30/15 and 6/14/12, revealed the following deficiencies:
- Gauges over 5 years old require calibration or replacement: on 4/30/15 and 6/14/12 reports.
- Fire department connections not visible nor accessible: on 4/30/15 report.
- Tamper switch failed to report to the panel: on 4/30/15 report.
- Obstruction investigation required every five years - last noted one was conducted 9/9/09: on 4/30/15 report.
The facility had no evidence of the deficiencies being addressed.

These findings were verified with Patient Data Manager Staff #2 on 6/10/15.

Based on observation and interview, the two Fire Department Connections (FDC) for the sprinkler system, on the outside of the building, were obstructed by vegetation.

Findings include:

Observation during facility tour on 6/10/15 revealed that the FDC at the front of the building, located to the right of the main entrance, was obstructed by a holly bush. The FDC at the back of the building, located near radiology, was obstructed by a yew bush. The FDCs were not visible from the parking lot or sidewalk and were not accessible.

This finding was verified with Patient Data Manager Staff #2 on 6/10/15.

Based on observation and interview, the facility does not ensure that all doors in the exit passageway close completely.

Findings include:

Observation during facility tour on 6/10/15 revealed:
- The door at grade level in stairwell "A", which leads to the outside, had the self-closer arm removed. The door was not self-closing.
- When viewing the double doors in the corridor near room #1113 with the main entrance at one's back, with the leaf on the right side, it was observed that the top of the door hits the header, preventing full closure of door by approximately two inches. The door when in the closed position requires a great amount of force to open, as the top of the door wedges into the header.

These findings were verified with Patient Data Manager Staff #2 on 6/10/15.

Based on document review and interview, the facility does not ensure that smoke head sensivity testing is performed, as evidenced for 2009 through 2015.

Findings include:

Review on 6/10/15 of Simplex Grinnell fire alarm system testing reports revealed reports dated: 11/2009, 5/2010, 11/2010, 5/2011, 11/2011, 5/2012, 11/2012, 5/2013, 11/2013, 5/2014, 11/2014 and 5/8/15. There was no evidence in the reports that smoke head sensitivity testing was performed.

This finding was verified by Patient Services Manager Staff #3 on 6/10/15.

Based on document review and interview, the facility does not maintain the sprinkler system as evidenced by the lack of addressing deficiencies noted on the inspector's reports.

Findings include:

Review on 6/10/15 of two facility-provided sprinkler reports, dated 4/30/15 and 6/14/12, revealed the following deficiencies:
- Gauges over 5 years old require calibration or replacement: on 4/30/15 and 6/14/12 reports.
- Fire department connections not visible nor accessible: on 4/30/15 report.
- Tamper switch failed to report to the panel: on 4/30/15 report.
- Obstruction investigation required every five years - last noted one was conducted 9/9/09: on 4/30/15 report.
The facility had no evidence of the deficiencies being addressed.

These findings were verified with Patient Data Manager Staff #2 on 6/10/15.

Based on observation and interview, the two Fire Department Connections (FDC) for the sprinkler system, on the outside of the building, were obstructed by vegetation.

Findings include:

Observation during facility tour on 6/10/15 revealed that the FDC at the front of the building, located to the right of the main entrance, was obstructed by a holly bush. The FDC at the back of the building, located near radiology, was obstructed by a yew bush. The FDCs were not visible from the parking lot or sidewalk and were not accessible.

This finding was verified with Patient Data Manager Staff #2 on 6/10/15.