HospitalInspections.org

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to protect the corridor opening. Louvers were in both doors at the laundry room and at the operating room doors allowing smoke to pass through. These doors must be replaced or modified to resist fire for minimum 20 minutes.

The double doors into the OR suite did not resist the passage of smoke since no astragal existed.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to maintain a door protecting the corridor opening at several locations. The corridor doors did not latch when closed into the dietary suite and the janitor closet across from laundry and the X-ray room and operating room, even though those doors were equipped with positive latching hardware.

Additionally corridor doors for emergency room 1 and 2, where patients would be located, were equipped with roller latching hardware. Roller latches do not provide for a positive latch when the door is closed.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to maintain the egress corridor. The laundry room ' s door was held in the open position by a wood wedge at the floor level.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to maintain the smoke barrier. Cross corridor smoke compartment doors did not close fully upon activation of the fire alarm, leaving a gap between the doors ' edges. The gap would permit the movement of smoke from one compartment to another in the facility.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to assure the protection of a hazardous room. A self closing or automatic-closing device was missing from the soiled utility door, near the nurse station.


Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to maintain a rated barrier. The door did not latch at the door frame when closed at the laundry room, which are hazardous areas.

Based on review of records during the survey of facility on the morning of 10/25/2011, with discussion with the Maintenance Supervisor, the facility failed to provide documentation showing that the fire drills were being conducted on every shift. The drills were being conducting quarterly though.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to provide " No Smoking " sign at the public entrance. The facility shall post signs to inform the people of their " no smoking " policy.

Oxygen cylinders are not approved. The facility must have piped in medical gases, not cylinders at patient care areas.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to provide, at emergency generator set location, a light fixture which illuminates the generator that is energized by battery power. The battery in turn must be charged by an electrical connection to a life safety branch panel board. The existing fluorescent light at the emergency generator appeared not to have a battery backup.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to provide, at emergency generator set location, an electrical receptacle. This receptacle is required to be red with the circuit and panel board numbers on the receptacle ' s plate. Per NFPA 99 ..... The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES panel board.
Four existing electrical receptacle near the emergency generator were white in color and appeared not be determined connected to generator power.

Based on review of records during the survey of facility on the afternoon of 8/05/2011, having discussions with the Director of Facility Maintenance, the facility failed to provide documentation that the emergency generator had been exercised under load monthly for 30 minutes.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to protect the corridor opening. Louvers were in both doors at the laundry room and at the operating room doors allowing smoke to pass through. These doors must be replaced or modified to resist fire for minimum 20 minutes.

The double doors into the OR suite did not resist the passage of smoke since no astragal existed.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to maintain a door protecting the corridor opening at several locations. The corridor doors did not latch when closed into the dietary suite and the janitor closet across from laundry and the X-ray room and operating room, even though those doors were equipped with positive latching hardware.

Additionally corridor doors for emergency room 1 and 2, where patients would be located, were equipped with roller latching hardware. Roller latches do not provide for a positive latch when the door is closed.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to maintain the egress corridor. The laundry room ' s door was held in the open position by a wood wedge at the floor level.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to maintain the smoke barrier. Cross corridor smoke compartment doors did not close fully upon activation of the fire alarm, leaving a gap between the doors ' edges. The gap would permit the movement of smoke from one compartment to another in the facility.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to assure the protection of a hazardous room. A self closing or automatic-closing device was missing from the soiled utility door, near the nurse station.


Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to maintain a rated barrier. The door did not latch at the door frame when closed at the laundry room, which are hazardous areas.

Based on review of records during the survey of facility on the morning of 10/25/2011, with discussion with the Maintenance Supervisor, the facility failed to provide documentation showing that the fire drills were being conducted on every shift. The drills were being conducting quarterly though.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to provide " No Smoking " sign at the public entrance. The facility shall post signs to inform the people of their " no smoking " policy.

Oxygen cylinders are not approved. The facility must have piped in medical gases, not cylinders at patient care areas.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to provide, at emergency generator set location, a light fixture which illuminates the generator that is energized by battery power. The battery in turn must be charged by an electrical connection to a life safety branch panel board. The existing fluorescent light at the emergency generator appeared not to have a battery backup.

Based on observations during the survey walk of the facility on the morning of 10/25/2011, while being accompanied by the Maintenance Supervisor, the facility failed to provide, at emergency generator set location, an electrical receptacle. This receptacle is required to be red with the circuit and panel board numbers on the receptacle ' s plate. Per NFPA 99 ..... The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. This receptacle must be powered from the electrical Type 1 EES panel board.
Four existing electrical receptacle near the emergency generator were white in color and appeared not be determined connected to generator power.

Based on review of records during the survey of facility on the afternoon of 8/05/2011, having discussions with the Director of Facility Maintenance, the facility failed to provide documentation that the emergency generator had been exercised under load monthly for 30 minutes.