HospitalInspections.org

Observations revealed that the smoke barriers are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. This deficient practice could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all of the residents, staff and visitors.

Findings include:
Observations of two smoke barriers, during the facility tour on September 28, 2011, between 12:45 pm and 3:30 pm, revealed that:

1) A 4 x 4 inch piece of gypsum wallboard was missing in room 204, above the ceiling,
2) A 4 inch triangle of gypsum wallboard was missing in room 202, above the ceiling,
3) There is an unsealed wire penetration through the wall in ER suite, above the ceiling,
4) There is an unsealed conduit penetration in the Same Day Surgery Suite, above the ceiling, and
5) There is an unsealed wire bundle through the wall in ER suite.

The Maintenance Supervisor (CM) verified these findings during the inspection and at the exit conference.

Observations revealed that two smoke detectors are within 3 feet of openings into the HVAC system and not installed in accordance with NFPA 72 " The National Fire Alarm Code" 1999 edition section 2-3.5.1. Improper location of smoke detectors may allow a delay in alarming staff, causing a delay in the response to the fire emergency, which would negatively impact all the residents, visitors and staff.

Findings include:
Observations during the facility tour on September 28, 2011, between 12:45 pm and 3:30 pm, revealed that the smoke detectors in the Internet Cafe are within 3 feet of the HVAC air diffusers.

The Maintenance Supervisor (CM) verified these findings during the inspection and at the exit conference.

Observations revealed that the main kitchen is not in accordance with NFPA 101 "The Life Safety Code" section 18.3.2.6. This deficient practice could allow a fire to spread into the corridor system which would negatively impact all the residents, staff and guests of the wing the fire is in.

Findings include:
Observations during the facility tour on September 28, 2011, between 12:45 pm and 3:30 pm, revealed that the kitchen has two roll down doors (one is into the dish room that is open to the kitchen) that are not automatically self-closing and do not close upon fire alarm activation thereby leaving the kitchen open to the dining room which is not separated from the corridor system.

The Maintenance Supervisor (CM) verified these findings during the inspection and at the exit conference.

Observations revealed that compressed gases are not in accordance with NFPA 99 Health Care Facilities edition 1999. Improperly stored oxygen can allow oxygen enriched atmosphere which could negatively impact the 16 residents, staff and guests in each neighborhood.

Findings include:
Observations during the facility tour on September 28, 2011, between 12:45 pm and 3:30 pm, revealed that the compressed gas cylinders in the Gas Storage and Manifold Room are not all independently secured firmly to the wall, and some are freestanding.

The Maintenance Supervisor (CM) verified these findings during the inspection and at the exit conference.

Observations revealed that the smoke barriers are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. This deficient practice could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all of the residents, staff and visitors.

Findings include:
Observations of two smoke barriers, during the facility tour on September 28, 2011, between 12:45 pm and 3:30 pm, revealed that:

1) A 4 x 4 inch piece of gypsum wallboard was missing in room 204, above the ceiling,
2) A 4 inch triangle of gypsum wallboard was missing in room 202, above the ceiling,
3) There is an unsealed wire penetration through the wall in ER suite, above the ceiling,
4) There is an unsealed conduit penetration in the Same Day Surgery Suite, above the ceiling, and
5) There is an unsealed wire bundle through the wall in ER suite.

The Maintenance Supervisor (CM) verified these findings during the inspection and at the exit conference.

Observations revealed that two smoke detectors are within 3 feet of openings into the HVAC system and not installed in accordance with NFPA 72 " The National Fire Alarm Code" 1999 edition section 2-3.5.1. Improper location of smoke detectors may allow a delay in alarming staff, causing a delay in the response to the fire emergency, which would negatively impact all the residents, visitors and staff.

Findings include:
Observations during the facility tour on September 28, 2011, between 12:45 pm and 3:30 pm, revealed that the smoke detectors in the Internet Cafe are within 3 feet of the HVAC air diffusers.

The Maintenance Supervisor (CM) verified these findings during the inspection and at the exit conference.

Observations revealed that the main kitchen is not in accordance with NFPA 101 "The Life Safety Code" section 18.3.2.6. This deficient practice could allow a fire to spread into the corridor system which would negatively impact all the residents, staff and guests of the wing the fire is in.

Findings include:
Observations during the facility tour on September 28, 2011, between 12:45 pm and 3:30 pm, revealed that the kitchen has two roll down doors (one is into the dish room that is open to the kitchen) that are not automatically self-closing and do not close upon fire alarm activation thereby leaving the kitchen open to the dining room which is not separated from the corridor system.

The Maintenance Supervisor (CM) verified these findings during the inspection and at the exit conference.

Observations revealed that compressed gases are not in accordance with NFPA 99 Health Care Facilities edition 1999. Improperly stored oxygen can allow oxygen enriched atmosphere which could negatively impact the 16 residents, staff and guests in each neighborhood.

Findings include:
Observations during the facility tour on September 28, 2011, between 12:45 pm and 3:30 pm, revealed that the compressed gas cylinders in the Gas Storage and Manifold Room are not all independently secured firmly to the wall, and some are freestanding.

The Maintenance Supervisor (CM) verified these findings during the inspection and at the exit conference.