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Based on observations, the facility failed to properly protect corridors in accordance to NFPA 101 sections 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5. These condition deficiencies affected the entire facility on day of survey.

Findings include:

On 6/7/16 between 11:20 AM and 2:00 PM, observation revealed revealed the corridor walls had numerous unsealed penetrations above the suspended ceiling in the Central and West Wings of the facility. It was also observed the one hour rated solid ceiling above the corridor walls of the Central and West Wings were damaged, contain open penetrations, and partial removed. An unrated window assembly was also installed in the corridor wall near the Wound Care Area of the facility. This facility was not protected by automatic fire sprinkler system.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

Based on observations, the facility failed to properly protect corridor openings in accordance to NFPA 101 19.3.6.3.6 and 19.3.6.3.2. These standard deficiencies have the potential to affect the entire facility on day of survey.


Findings Include:

On 6/7/16 between 10:00 AM and 11:00 AM, observation revealed kick stops on the doors to the Locker Room, Patient Room 127, Omni Cell Room, Kitchen, Dining Room, and Dietary which impeded the door from closing and allow the passage of smoke to the main corridors of the facility. Observation also revealed the door of the Admissions Office had an unapproved roller latch. The doors to the Medical Unit Janitor ' s Closet and Patient Room 061 had air transfer grilles, which can allow the passage of smoke to the main corridor of the facility.

The door to the Pharmacy, which was a Dutch door, lacked a latching mechanism on the top leaf of the door.

The doors to Patient Rooms 015,116, 117, 118, 119, 112 and 231 did not properly close, latch, and seal, which can allow the passage of smoke to the main corridor of the facility.

The door to the Bathroom in the Wound Care Area was a not a solid wood door and did contain 20 minute fire rating.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

19.3.6.3.6
Dutch doors shall be permitted where they conform to 18.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.
Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Based on observations and interviews, the facility failed to properly provide and maintain the smoke barrier walls in accordance to NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5. This condition deficiency had the potential to affect the entire facility on day of survey.

Findings Include:

On 6/7/16 at 11:00 AM, observation and interview with Maintenance Supervisor revealed the facility was unable to provide the locations of the smoke barrier walls of the facility. An observation was made in an attempt to locate the smoke barrier walls but the walls observed were unsealed and not continuing through the entire facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

Based on observations, the facility failed to properly protect hazardous areas in accordance to NFPA 101 section 19.3.5.4. These standard deficiencies have the potential to affect the entire facility on day of survey.

Findings Include:

On June 7, 2016 at 11:40 AM, observation revealed the doors to the Patient Rooms 031 and 122 lacked automatic closing devices. These Patient Rooms 031 and 022 were being used as storage of combustible materials and furniture.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

Based on observations, the facility failed to provide readily accessible exit access as defined by NFPA chapter 7.2.1.5.4 and 19.2.2.2.4. These standard deficiencies have the potential to affect the entire facility on day of survey.

Findings include:

On June 7, 2016 at 11:10 AM, observation revealed the doors of X-Ray Rooms 1, X-Ray Room 2, and Kitchen had a locking device located above 48 " from the finished floor. The exit door from the Wound Care Area and the smoke door near Room 218 had a double keyed dead bolt lock. The doors of the resident rooms in the Wound Care Area had dead bolt locks.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing
installations.

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observations, the facility failed to properly maintain fire extinguishers as per NFPA 10 4 - 4.3, and NFPA 10 4-4.4.2. This standard deficiency had the potential to affect the entire facility on day of survey.

Findings Include:

On June 7, 2016 at 12:20 PM, the K Class fire extinguisher
located in the Kitchen was dated 1998 but no documentation evidence could be produced detailing a six year or 12 year maintenance inspection.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

NFPA 10 4-4.3
Six-Year Maintenance.
Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.
4-4.4.2* Verification of Service (Maintenance or Recharging).
Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a " Verification of Service " collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The " Verification of Service " collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.
Exception No. 1: Fire extinguishers undergoing maintenance before January 1, 1999.
Exception No. 2: Cartridge/cylinder-operated fire extinguishers do not require a " Verification of Service " collar.

Based on document review, the facility failed to properly maintain the emergency generator as per NFPA 110 A-6-3.1. This standard deficiency had the potential to affect the entire facility on day of survey.

Findings include:

On June 7, 2016 at 11:40 AM, the facility was unable to provide documentation showing that the generator had received an annual inspection in the last year. The last documented annual inspection was dated April 28, 2015. The generator was tested, cranked, and transferred within the allotted 10 second interval.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

Based on observations, the facility failed to properly protect corridors in accordance to NFPA 101 sections 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5. These condition deficiencies affected the entire facility on day of survey.

Findings include:

On 6/7/16 between 11:20 AM and 2:00 PM, observation revealed revealed the corridor walls had numerous unsealed penetrations above the suspended ceiling in the Central and West Wings of the facility. It was also observed the one hour rated solid ceiling above the corridor walls of the Central and West Wings were damaged, contain open penetrations, and partial removed. An unrated window assembly was also installed in the corridor wall near the Wound Care Area of the facility. This facility was not protected by automatic fire sprinkler system.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

Based on observations, the facility failed to properly protect corridor openings in accordance to NFPA 101 19.3.6.3.6 and 19.3.6.3.2. These standard deficiencies have the potential to affect the entire facility on day of survey.


Findings Include:

On 6/7/16 between 10:00 AM and 11:00 AM, observation revealed kick stops on the doors to the Locker Room, Patient Room 127, Omni Cell Room, Kitchen, Dining Room, and Dietary which impeded the door from closing and allow the passage of smoke to the main corridors of the facility. Observation also revealed the door of the Admissions Office had an unapproved roller latch. The doors to the Medical Unit Janitor ' s Closet and Patient Room 061 had air transfer grilles, which can allow the passage of smoke to the main corridor of the facility.

The door to the Pharmacy, which was a Dutch door, lacked a latching mechanism on the top leaf of the door.

The doors to Patient Rooms 015,116, 117, 118, 119, 112 and 231 did not properly close, latch, and seal, which can allow the passage of smoke to the main corridor of the facility.

The door to the Bathroom in the Wound Care Area was a not a solid wood door and did contain 20 minute fire rating.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

19.3.6.3.6
Dutch doors shall be permitted where they conform to 18.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.
Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Based on observations and interviews, the facility failed to properly provide and maintain the smoke barrier walls in accordance to NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5. This condition deficiency had the potential to affect the entire facility on day of survey.

Findings Include:

On 6/7/16 at 11:00 AM, observation and interview with Maintenance Supervisor revealed the facility was unable to provide the locations of the smoke barrier walls of the facility. An observation was made in an attempt to locate the smoke barrier walls but the walls observed were unsealed and not continuing through the entire facility.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

Based on observations, the facility failed to properly protect hazardous areas in accordance to NFPA 101 section 19.3.5.4. These standard deficiencies have the potential to affect the entire facility on day of survey.

Findings Include:

On June 7, 2016 at 11:40 AM, observation revealed the doors to the Patient Rooms 031 and 122 lacked automatic closing devices. These Patient Rooms 031 and 022 were being used as storage of combustible materials and furniture.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

Based on observations, the facility failed to provide readily accessible exit access as defined by NFPA chapter 7.2.1.5.4 and 19.2.2.2.4. These standard deficiencies have the potential to affect the entire facility on day of survey.

Findings include:

On June 7, 2016 at 11:10 AM, observation revealed the doors of X-Ray Rooms 1, X-Ray Room 2, and Kitchen had a locking device located above 48 " from the finished floor. The exit door from the Wound Care Area and the smoke door near Room 218 had a double keyed dead bolt lock. The doors of the resident rooms in the Wound Care Area had dead bolt locks.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing
installations.

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Based on observations, the facility failed to properly maintain fire extinguishers as per NFPA 10 4 - 4.3, and NFPA 10 4-4.4.2. This standard deficiency had the potential to affect the entire facility on day of survey.

Findings Include:

On June 7, 2016 at 12:20 PM, the K Class fire extinguisher
located in the Kitchen was dated 1998 but no documentation evidence could be produced detailing a six year or 12 year maintenance inspection.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.

NFPA 10 4-4.3
Six-Year Maintenance.
Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.
4-4.4.2* Verification of Service (Maintenance or Recharging).
Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a " Verification of Service " collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The " Verification of Service " collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.
Exception No. 1: Fire extinguishers undergoing maintenance before January 1, 1999.
Exception No. 2: Cartridge/cylinder-operated fire extinguishers do not require a " Verification of Service " collar.

Based on document review, the facility failed to properly maintain the emergency generator as per NFPA 110 A-6-3.1. This standard deficiency had the potential to affect the entire facility on day of survey.

Findings include:

On June 7, 2016 at 11:40 AM, the facility was unable to provide documentation showing that the generator had received an annual inspection in the last year. The last documented annual inspection was dated April 28, 2015. The generator was tested, cranked, and transferred within the allotted 10 second interval.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 6/7/16.