HospitalInspections.org

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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.1, and 7.2.1.5.1

This deficiency affects 9 of 14 Patient Room Bathrooms.

Findings include:

During a tour of the facility, the surveyor observed dead bolt locks on the non-egress side of the following Patient Room Bathroom doors; there was no mechanism to unlock these doors on the egress side:

1. 200
2. 201
3. 202
4. 203
5. 204
6. 205
7. 206
8. 208
9. 210

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the exit signage per the requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.2.1

This deficiency affects the Lobby exit sign.

Findings include:

During a tour of the facility, the surveyor observed the exit sign over the Main Entrance Lobby Egress Door had two chevron-type indicators directing egress to the left and the right. The correct direction for emergency egress is straight through the door.

A member of the maintenance staff was present when the deficiency was identified.

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Based on observation, the facility failed to provide an approved method to ensure appliances that are protected under the hoods, if they are moved, they are returned to the approved design location per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1

This deficiency affects all equipment under the two kitchen hoods.

Findings include:

During a tour of the facility, the surveyor observed that the facility failed to provide an approved method to ensure appliances that are protected under the hoods, if they are moved, they are returned to the approved design location.

A member of maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 14.2.1

This deficiency affects the automatic sprinkler system.

Findings include:

During the review of the documentation, the facility failed to provide documentation of conducting the automatic sprinkler internal pipe inspection during the past 5 years.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on observation, the facility failed to ensure the lay-in ceiling limited the transfer of smoke per the requirements of:

2012 NFPA 101, 19.3.6.2.4

This deficiency affects the Information Technology Room.

Findings include:

During a tour of the facility, the surveyor observed eleven, 2' x 2' ceiling tiles were missing in the Information Technology Room.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3

This deficiency affects 1 of 3 smoke barriers.

Findings include:

During a tour of the facility, the surveyor observed a 1" unsealed conduit (used as a cable chase) with multiple white cables above the ceiling on both sides of the smoke barrier between 200 Hall and the Nurses Station.

A member of the maintenance staff was present when this deficiency was identified.