HospitalInspections.org

Based on observation, staff interviews and review of maintenance documents, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the 10 smoke compartments, and had the potential to affect all of the 26 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 9/28/10 surveyor #14105 learned that the facility had the following deficiencies remaining:
K-18 (corridor doors),
K-29 (hazardous areas),
K-51 (fire alarm appliances),
Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Lead Engineer), and staff L (Engineer).

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain the building systems to ensure a life safety environment in the building to meet the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and "Existing Healthcare Occupancy" chapters of this code. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the 10 smoke compartments, and had the potential to affect all of the 26 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 09/28/10 at am surveyor #14105 learned that the facility had the following life safety deficiencies remaining:
K-18 (corridor doors),
K-29 (hazardous areas),
K-51 (fire alarm appliances).
Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41(b). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Lead Engineer), and staff L (Engineer).