HospitalInspections.org

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency occurred in 2 of the 5 smoke compartments and had the potential to affect 12 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 2/29/2016 at 1:41 pm surveyor observed on the Ground floor in the PT Storage Room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

2. On 2/29/2016 at 1:49 pm surveyor observed on the Ground floor in the Central Purchasing Room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

3. On 2/29/2016 at 2:12 pm surveyor observed on the Ground floor in the Soiled Linen Room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 1 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 3/1/2016 at 10:10 am surveyor observed on the First floor in the OR Room, that the battery back-up light did not light when tested. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on record review and interview, the facility did not conduct fire drills in accordance with NFPA 13 and as required by the Life Safety Code, section 9.7.1.1. This deficiency occurred in all of the 5 smoke compartments and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors

FINDINGS INCLUDE
On 3/1/2016 at 12:50 pm during a review of facility fire drill documents for the third shift of the fourth quarter of 2015 the documents could not be located. This situation was not compliant with NFPA 101 (2000 edition), 19.7.1.2. The condition was confirmed by a concurrent record review and interview at the time of discovery .

:

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The facility did not provide a sprinkler system with unobstructed water distribution, sprinklers located the appropriate distance apart, and sprinklers located the appropriate distance from walls. This deficiency occurred in 2 of the 5 smoke compartments and had the potential to affect 12 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 2/29/2016 at 2:51 pm surveyor observed on the Ground floor in the Laundry, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a large card board box stored within 8" of a sprinkler head. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

2. On 3/1/2016 at 10:51 am surveyor observed on the First floor in the Surgical Supply Room, that (1) sidewall sprinkler head was located in a room that is approximately 15' x 18' with the head being 18' from the opposite wall. Sprinklers cannot be farther from each other than the maximum required separation distance of 15' for standard discharge heads or farther than 7-1/2' from a wall. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

3. On 2/29/2016 at 2:15 pm surveyor observed on the Ground floor in the Laundry, that a sprinkler was located near a pair of doors and located approximately 1 1/2" off a wall. Sprinklers cannot be closer than 4" to a wall to avoid disruption of the water spray pattern. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 2 of the 5 smoke compartments and had the potential to affect 6 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 2/29/2016 at 2:41 pm surveyor observed on the Ground floor in the Locker Room, that the escutcheon ring is missing off a sprinkler head. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

2. On 2/29/2016 at 2:46 pm surveyor observed on the Ground floor in the Housekeeping Room, that the escutcheon ring on the sprinkler was loose. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

3. On 3/1/2016 at 10:58 am surveyor observed on the First floor in the Ultra Sound Room, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

4. On 2/29/2016 at 1:51 pm surveyor observed on the Ground floor in the Housekeeping Room, that there was one or more unsealed holes near the ceiling. The hole(s) included (4) ceiling tiles out of place. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

5. On 2/29/2016 at 2:16 pm surveyor observed on the Ground floor in the Laundry, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. Three sprinkler heads were covered with lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with oxygen cylinders restrained from falling. This deficiency occurred in 1 of the 5 smoke compartments and had the potential to affect 5 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 3/1/2016 at 11:15 am surveyor observed on the First floor in the Storage Room, that cylinders of oxygen in storage were not secured to keep them from falling. An oxygen tank was free standing and not in a container. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 8-3.1.11. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with closed electrical raceways. This deficiency occurred in 1 of the 5 smoke compartments and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 3/1/2016 at 11:08 am surveyor observed on the First floor in the X-Ray Area, that a open electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency occurred in 2 of the 5 smoke compartments and had the potential to affect 12 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 2/29/2016 at 1:41 pm surveyor observed on the Ground floor in the PT Storage Room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

2. On 2/29/2016 at 1:49 pm surveyor observed on the Ground floor in the Central Purchasing Room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

3. On 2/29/2016 at 2:12 pm surveyor observed on the Ground floor in the Soiled Linen Room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 1 of the 5 smoke compartments, and had the potential to affect 1 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 3/1/2016 at 10:10 am surveyor observed on the First floor in the OR Room, that the battery back-up light did not light when tested. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on record review and interview, the facility did not conduct fire drills in accordance with NFPA 13 and as required by the Life Safety Code, section 9.7.1.1. This deficiency occurred in all of the 5 smoke compartments and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors

FINDINGS INCLUDE
On 3/1/2016 at 12:50 pm during a review of facility fire drill documents for the third shift of the fourth quarter of 2015 the documents could not be located. This situation was not compliant with NFPA 101 (2000 edition), 19.7.1.2. The condition was confirmed by a concurrent record review and interview at the time of discovery .

:

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The facility did not provide a sprinkler system with unobstructed water distribution, sprinklers located the appropriate distance apart, and sprinklers located the appropriate distance from walls. This deficiency occurred in 2 of the 5 smoke compartments and had the potential to affect 12 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 2/29/2016 at 2:51 pm surveyor observed on the Ground floor in the Laundry, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a large card board box stored within 8" of a sprinkler head. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

2. On 3/1/2016 at 10:51 am surveyor observed on the First floor in the Surgical Supply Room, that (1) sidewall sprinkler head was located in a room that is approximately 15' x 18' with the head being 18' from the opposite wall. Sprinklers cannot be farther from each other than the maximum required separation distance of 15' for standard discharge heads or farther than 7-1/2' from a wall. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

3. On 2/29/2016 at 2:15 pm surveyor observed on the Ground floor in the Laundry, that a sprinkler was located near a pair of doors and located approximately 1 1/2" off a wall. Sprinklers cannot be closer than 4" to a wall to avoid disruption of the water spray pattern. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of lint. This deficiency occurred in 2 of the 5 smoke compartments and had the potential to affect 6 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 2/29/2016 at 2:41 pm surveyor observed on the Ground floor in the Locker Room, that the escutcheon ring is missing off a sprinkler head. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

2. On 2/29/2016 at 2:46 pm surveyor observed on the Ground floor in the Housekeeping Room, that the escutcheon ring on the sprinkler was loose. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

3. On 3/1/2016 at 10:58 am surveyor observed on the First floor in the Ultra Sound Room, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

4. On 2/29/2016 at 1:51 pm surveyor observed on the Ground floor in the Housekeeping Room, that there was one or more unsealed holes near the ceiling. The hole(s) included (4) ceiling tiles out of place. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

5. On 2/29/2016 at 2:16 pm surveyor observed on the Ground floor in the Laundry, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. Three sprinkler heads were covered with lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with oxygen cylinders restrained from falling. This deficiency occurred in 1 of the 5 smoke compartments and had the potential to affect 5 of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 3/1/2016 at 11:15 am surveyor observed on the First floor in the Storage Room, that cylinders of oxygen in storage were not secured to keep them from falling. An oxygen tank was free standing and not in a container. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 8-3.1.11. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with closed electrical raceways. This deficiency occurred in 1 of the 5 smoke compartments and had the potential to affect 3 of the 25 residents that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 3/1/2016 at 11:08 am surveyor observed on the First floor in the X-Ray Area, that a open electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Environmental Services/Safety Manager).