HospitalInspections.org

6/17/2013 - "waiver requested/approved for the following defeciency":

Based on observation and testing, the facility failed to provide the two hour fire separation between nonconforming building.

Findings include:

While inspecting the separation wall between the main building and the 2 story addition, on March 19, 2013 at 11:00 a.m., the surveyor and maintenance director observed the two hour fire separation had numerous penetrations throughout the entire wall.

This deficient practice has the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference

6/17/2013 - "waiver requested/approved for the following defeciency":

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4.

Findings include:

While inspecting smoke barrier walls on March 19, 2013 at 1:30 p.m., the maintenance supervisor could not provide any life safety documentation on where smoke barrier walls were located in the facility. The walls that were believed to be smoke barriers had numerous penetrations throughout the entire facility.

This deficient practice has the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

6/17/2013 - "waiver requested/approved for the following defeciency":

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

While inspecting hazardous areas on March 19. 2013 at 11:45 a.m., the maintenance person and the the surveyor found the following hazardous areas to have deficiencies:
1. Soiled Linen Room on the second floor did not have a self closing device installed and should be 1-hour rated.
2. Central Storage located in the basement did not have walls constructed that could resist the passage of smoke.
3. Radiology Storage Room did not have self closing device installed on door.
4. Oxygen Storage Room did not have a self closing device installed on door.
5. Generator Room located in the basement had unsealed penetrations in the walls.
6. Storage Room located behind the lab could not resist the passage of smoke because of numerous penetrations and did not have doors with frames that could resist the passage of smoke. Also self closing devices are needed on all 3 doors.
7. Medical Storage Room located on the second floor should be 1-hour rated.

This deficient practice has the potential of affecting the entire facility. The administrator and maintenance director were notified during the survey and in the exit conference.

6/17/2013 - "waiver requested/approved for the following defeciency":

Based on observation and testing, the facility failed to provide the exit components (such as stairways) that are enclosed with construction having a fire resistance rating of at least one hour, that are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1

Findings include:

While inspecting the exit components on March 19, 2013 at 11:30 a.m., the surveyor and maintenance director observed two stairways that exited into the corridor on the first floor. The exit passage way did not provide a one hour protection to the exit. The corridor walls had numerous penetrations throughout the length of the passage way.

This deficient practices have the potential of effecting the entire facility. The maintenance supervisor and the administrator were notified during an exit conference.

6/17/2013 - "waiver requested/approved for the following defeciency":

Based on observation and record review, the facility failed to properly install electrical wiring and equipment in accordance with NFPA 70, National Electrical Code 9.1.2

Findings include:

While inspecting electrical wiring on March 19, 2013 at 11:20 a.m., the surveyor and maintenance supervisor notice numerous junction boxes that lacked a cover. Several junction boxes throughout the facility had wiring extending about 3 feet out of the box that was exposed and hanging above the ceiling.

This deficient practice has the potential of affecting the entire facility. The administrator as well as the maintenance director was notified during the survey as well as the exit conference.