HospitalInspections.org

Based on observation during the life safety survey completed on 12/09/14, the facility did not maintain stairwell access doors to be 90 minute rated as required.

Findings:

The west stairwell access door was observed to have four 1/4' holes in the door where hardware has been removed. These holes may compromise the rating of the door and render it incapable of fully resisting the passage of smoke or toxic fumes in the event of a fire.

This observation was made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 12/09/14, the facility did not maintain stairwell egress as required.

Findings:

The west stairwell main level of egress was observed to be lacking a swing gate deterrent to the basement level of the stairwell as required.

This observation was made in the presence of the maintenance supervisor.

Based on observation during the life safety survey completed on 12/09/14, the facility did not maintain ABHR (alcohol based hand rub) dispensers in accordance with CMS requirements.

Findings:

Two ABHR dispensers were observed to be installed directly inline above either electrical outlets or light switches: Rooms 3104, 3101 and in the clean linen closet.

These observations were made in the presence of the maintenance supervisor.