HospitalInspections.org

K211
This standard is not met as evidenced by:
Based on observation and interview, the provider failed to ensure one exit door and three exit access corridors were maintained free of obstructions which could impede egress during an emergency (e.g., a fire event).
Findings include:

1. Observation on 7/15/25 at 11:30 a.m. revealed the laundry/maintenance exit access corridor contained a large variety of obstructions, including combustibles (items in cardboard boxes).

2. Observation on 7/15/25 at 11:50 a.m. revealed the back hallway exit access corridor contained a variety of obstructions, including combustibles.

3. Observation on 7/15/25 at 12:25 p.m. revealed the exit door from the loading dock storage room was partially blocked by obstructions appearing to be refuse on the floor, including combustibles (items in cardboard boxes).

4. Observation on 7/15/25 at 12:30 p.m. revealed the exit access corridor between the hospital and dialysis center contained a variety of obstructions, including large furniture items which did not have flame spread ratings.

Interview with the Finance Director and Maintenance Supervisor at the time of those observations confirmed those findings.

This deficiency compromised one of ten building exit doors and three of seven exit access corridors.

This standard is not met as evidenced by:
Based on observation and interview, the provider failed to maintain two hazardous area enclosure doors.
Findings include:

1. Observation on 7/15/25 at 10:50 a.m. revealed the door separating the boiler room, a hazardous area, from the mechanical/electrical room was held open by a rope tied between the doorknob and a conduit on the wall. The door was equipped with a closer.

2. Observation on 7/15/25 at 11:25 a.m. revealed the door separating the laundry room, a hazardous area, from the employee locker room did not self-close or latch. The door was equipped with a closer.

Interview with the Finance Director and Maintenance Supervisor at the time of those observations confirmed those findings.

These deficiencies compromised two of seven smoke compartments.

This standard is not met as evidenced by:
Based on observation and interview, the provider failed to maintain the smoke resistant partitions for four hazardous area enclosures.
Findings include:

1. Observation on 7/15/25 at 11:20 a.m. revealed one approximately two-inch open pipe penetration through the ceiling of the boiler mechanical room for the instrument sanitizer.

2. Observation on 7/15/25 at 11:35 a.m. revealed four open spaces around approximately six-inch pipe penetrations through the west wall of the maintenance shop.

3. Observation on 7/15/25 at 12:15 p.m. revealed six open spaces around pipe penetrations of various sizes through the north wall of the biohazard storage room.

4. Observation on 7/15/25 at 12:40 p.m. revealed three open spaces around pipe penetrations of various sizes through upper wall areas near the northwest corner of the long-term dialysis storage room.

Interview with the Finance Director and Maintenance Supervisor at the time of those observations confirmed those findings.

These deficiencies compromised three of seven smoke compartments.

This standard is not met as evidenced by:
Based on observation and interview, the provider failed to properly store oxidizing gases with a combined total volume of approximately 1,500 cubic feet.
Findings include:

1. Observation on 7/15/25 at 12:00 p.m. revealed two S-size cylinders containing 65 pounds each of nitrous oxide, which were co-located with various other medical gases (e.g., nitrogen), and 18 E-size and 3 B-size cylinders containing oxygen which were in a rack approximately 20 feet away from the nitrous oxide and other gas cylinders. There were a number of combustibles located within five feet of both cylinder collections including cardboard, cloth blankets and towels, plastics, and wooden furniture.

Interview with the Finance Director and Maintenance Supervisor at the time of the observation confirmed the finding.

This deficiency compromised one of seven smoke compartments.