HospitalInspections.org

Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the doors on stairwell #3A, soiled utility room #4052 and soiled utility room #1197 in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 12:58pm, by observation and interview of the Corporate Director of Building and Grounds, the door on stairwell #3A failed to close and latch properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/28/10 at approximately 1:01pm, by observation and interview of the Corporate Director of Building and Grounds, the door on the soiled utility room #4052 failed to close and latch properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 10:37am, by observation and interview of the Corporate Director of Building and Grounds, the door on the soiled utility room #1197 failed to close and latch properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the smoke barrier doors located at room #3056 and at room #1067 in accordance with the LSC, section 19.2.2.2.6. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 1:44pm, by observation and interview of the Corporate Director of Building and Grounds, the smoke barrier door at room #3056 failed to closed properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 9:52am, by observation and interview of the Corporate Director of Building and Grounds, the smoke barrier door at room #1067 failed to closed properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke barrier walls in the electrical room across from room #G880 and the storage room #1873 in accordance with the LSC, section 19.3.7.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 11:35am, by observation and interview of the Corporate Director of Building and Grounds, penetrations of the smoke barrier wall in the electrical room across from room #G880 failed to be properly sealed. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 10:03am, by observation and interview of the Corporate Director of Building and Grounds, penetrations of the smoke barrier wall in storage room #1873 failed to be properly sealed. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to provide and maintain the vertical opening protection of exits required by the LSC, section 19.2.1 and 19.3.1.1 by having rating labels painted on rated doors at the smoke barrier wall at room #G097, smoke barrier wall at the Auditorium and the smoke barrier wall at Pediatrics. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 10:58am, by observation and interview of the Corporate Director of Building and Grounds, the label on the rated door at the smoke barrier wall at room #G097 was painted and the fire resistance rating of the door could not be determined. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/28/10 at approximately 11:20am, by observation and interview of the Corporate Director of Building and Grounds, the label on the rated door at the smoke barrier wall at the Auditorium was painted and the fire resistance rating of the door could not be determined. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 10:10am, by observation and interview of the Corporate Director of Building and Grounds, the label on the rated door at the smoke barrier wall at Pediatrics was painted and the fire resistance rating of the door could not be determined. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that staff to be familiar with the facilities fire evacuation procedures by failing to conduct fire drills for second shift at varying times in the first, second and third quarters of 2010 in accordance with the LSC, section 19.7.1.2. This deficient practice could affect all occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 9:15am, during record review and interview of the Corporate Director of Building and Grounds, the facility failed to conduct and document fire drills for second shift for the first, second and third quarters of 2010 at varying times. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that the generator was inspected and exercised under a FULL LOAD BANK test in accordance with NFPA 99, section 3.4.4.1. This deficient practice could affect all occupants including residents, staff and visitors.
Findings Include:

On 10/28/10 at approximately 9:34am, during record review and interview of the Corporate Director of Building and Grounds, records were not available to verify that the facility had conducted the required FULL LOAD BANK test for the facilities generator. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure electrical wiring to be in accordance with NFPA 70, National Electrical Code, section 9.1.2 by using extension cords for permanent wiring in the 5th floor Refrigeration Shop and having an open electrical junction box above the ceiling at room #2126. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 12:40pm, by observation and interview of the Corporate Director of Building and Grounds, the facility was using an extension cord for permanent wiring on the 5th floor Refrigeration Shop. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 9:21am, by observation and interview of the Corporate Director of Building and Grounds, the facility failed to cover an open electrical junction box above the ceiling at room #2126. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the doors on stairwell #3A, soiled utility room #4052 and soiled utility room #1197 in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 12:58pm, by observation and interview of the Corporate Director of Building and Grounds, the door on stairwell #3A failed to close and latch properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/28/10 at approximately 1:01pm, by observation and interview of the Corporate Director of Building and Grounds, the door on the soiled utility room #4052 failed to close and latch properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 10:37am, by observation and interview of the Corporate Director of Building and Grounds, the door on the soiled utility room #1197 failed to close and latch properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the smoke barrier doors located at room #3056 and at room #1067 in accordance with the LSC, section 19.2.2.2.6. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 1:44pm, by observation and interview of the Corporate Director of Building and Grounds, the smoke barrier door at room #3056 failed to closed properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 9:52am, by observation and interview of the Corporate Director of Building and Grounds, the smoke barrier door at room #1067 failed to closed properly when tested. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke barrier walls in the electrical room across from room #G880 and the storage room #1873 in accordance with the LSC, section 19.3.7.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 11:35am, by observation and interview of the Corporate Director of Building and Grounds, penetrations of the smoke barrier wall in the electrical room across from room #G880 failed to be properly sealed. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 10:03am, by observation and interview of the Corporate Director of Building and Grounds, penetrations of the smoke barrier wall in storage room #1873 failed to be properly sealed. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to provide and maintain the vertical opening protection of exits required by the LSC, section 19.2.1 and 19.3.1.1 by having rating labels painted on rated doors at the smoke barrier wall at room #G097, smoke barrier wall at the Auditorium and the smoke barrier wall at Pediatrics. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 10:58am, by observation and interview of the Corporate Director of Building and Grounds, the label on the rated door at the smoke barrier wall at room #G097 was painted and the fire resistance rating of the door could not be determined. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/28/10 at approximately 11:20am, by observation and interview of the Corporate Director of Building and Grounds, the label on the rated door at the smoke barrier wall at the Auditorium was painted and the fire resistance rating of the door could not be determined. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 10:10am, by observation and interview of the Corporate Director of Building and Grounds, the label on the rated door at the smoke barrier wall at Pediatrics was painted and the fire resistance rating of the door could not be determined. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that staff to be familiar with the facilities fire evacuation procedures by failing to conduct fire drills for second shift at varying times in the first, second and third quarters of 2010 in accordance with the LSC, section 19.7.1.2. This deficient practice could affect all occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 9:15am, during record review and interview of the Corporate Director of Building and Grounds, the facility failed to conduct and document fire drills for second shift for the first, second and third quarters of 2010 at varying times. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that the generator was inspected and exercised under a FULL LOAD BANK test in accordance with NFPA 99, section 3.4.4.1. This deficient practice could affect all occupants including residents, staff and visitors.
Findings Include:

On 10/28/10 at approximately 9:34am, during record review and interview of the Corporate Director of Building and Grounds, records were not available to verify that the facility had conducted the required FULL LOAD BANK test for the facilities generator. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure electrical wiring to be in accordance with NFPA 70, National Electrical Code, section 9.1.2 by using extension cords for permanent wiring in the 5th floor Refrigeration Shop and having an open electrical junction box above the ceiling at room #2126. This deficient practice could affect an isolated number of occupants including residents, staff and visitors. Findings Include:

On 10/28/10 at approximately 12:40pm, by observation and interview of the Corporate Director of Building and Grounds, the facility was using an extension cord for permanent wiring on the 5th floor Refrigeration Shop. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.

On 10/29/10 at approximately 9:21am, by observation and interview of the Corporate Director of Building and Grounds, the facility failed to cover an open electrical junction box above the ceiling at room #2126. This finding was verified with the Corporate Director of Building and Grounds at the time of discovery.