HospitalInspections.org

Through observation during the survey August 21, 2013, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Director of Plant Operations and Administrator, one (1) resident room door did not latch into the frame to create a smoke sill.

Through observation, during the survey, August 21, 2013, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the Hospital and other facilities.

During the walk through of the facility, with the staff, the facility failed to maintain the two-hour separation wall between the hospital and other occupants in the building. Section 19.1.2.3 states "Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions per 19.1.1.4."

Several unsealed penetrations were found above the ceiling at the "UNIT B" entrance.

Through observation during the survey, August 21, 2013, it was determined that the facility failed to arrange the exit access so that exits are properly identified at all times.

During the walk through of the facility, with staff, the glass door which to the courtyard were not properly identified as "NO EXIT". (CORRECTED ON SITE)

Through record review and staff interview, during the survey conducted August 21, 2013, it was determined that the facility failed to conduct fire drills the minimum of once per quarter per shift, in accordance with 19.7.1.2.

During the review of the facilities records as part of the on-site survey, with staff, the facility failed to provide documentation showing that fire drills were conducted for the evening shift for the 1st and 2nd quarter of 2013.

Through observation and record review during the survey, during the survey August 21, 2013, it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.

During the walk through of the facility, with staff, the fire sprinkler riser was found to be actively leaking within the riser room.

Through record review during the survey, August 21, 2013, it was determined that the facility failed to exercise the generator per NFPA 110.

During the review of the facility records, with the Maintenance Director, documentation shows that the monthly amperage load testing of the generator does not meet or exceed the required 30 % monthly (this by its self is not deficient). When the generator is tested monthly but does not meet the 30 % load amperage, a load bank test must be conducted annually. The documentation shows that a load bank test was conducted, but the required 75% was not met for the last hour (documentation shows 73%).