HospitalInspections.org

Based on observation and interview, the facility has a corridor door that does not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect all patients.

Findings include:

During the facility tour on 10-30-12 at 10:00 AM observation revealed that the door to the sterile processing room has had the latch covered with tape, and the door will not latch securely in the frame provided.

These deficient practices were verified by the fFacility Services Manager at the time of the inspection.

Based on observations, the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all residents, staff and visitors as smoke from a fire in this room could enter the corridor making it untenable.

Findings include:

During the facility tour on 10-30-12 at 2:30 PM it was observed that the Boiler Room door 1414 had an improper latching assembly on it and that the door was locked from the exterior with a pad lock and hasp arrangement.


This deficient practice was verified by the Facility Services Manager at the time of inspection.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of the patients in an emergency situation.

Findings include:

During the facility tour on 10-29-12 between 1:00-3:00 PM it was observed, that the facility has drop down from the wall charting tables, aka, "walleroos". When tested, several "walleroos" would not retract to the closed position. They are located in the patient care areas near rooms 403, 404, 405, & 406.

This deficient practice was confirmed by the Facilities Services Manager at the time of inspection.

Based on observations, the facility had oxygen storage not meeting the requirements of NFPA 99. This deficient practice could affect all residents, staff and visitors.

Findings include:

During the facility tour on 10-30-12 at 2:30 PM, it was observed that the required exhaust from the medical gas storage room on the second floor does not go into a one hour rated shaft.

This deficient practice was confirm by the Facility Services Manager at the time of inspection.

Based on observation and interview, the facility oxygen storage area(S) did not have the proper signage in accordance with 19.3.2.4, NFPA, 8.6.4.2.

Findings include:

During the facility tour on 10-30-12 at 1:00 PM it was observed that not all locations where oxygen is being stored are labeled as "NO SMOKING".

This deficient practice was confirmed by the Facility Services Manager at the time of inspection.

Based on observation and interview, the facility has a corridor door that does not meet the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect all patients.

Findings include:

During the facility tour on 10-30-12 at 10:00 AM observation revealed that the door to the sterile processing room has had the latch covered with tape, and the door will not latch securely in the frame provided.

These deficient practices were verified by the fFacility Services Manager at the time of the inspection.

Based on observations, the facility has failed to provide proper protection from 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all residents, staff and visitors as smoke from a fire in this room could enter the corridor making it untenable.

Findings include:

During the facility tour on 10-30-12 at 2:30 PM it was observed that the Boiler Room door 1414 had an improper latching assembly on it and that the door was locked from the exterior with a pad lock and hasp arrangement.


This deficient practice was verified by the Facility Services Manager at the time of inspection.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of the patients in an emergency situation.

Findings include:

During the facility tour on 10-29-12 between 1:00-3:00 PM it was observed, that the facility has drop down from the wall charting tables, aka, "walleroos". When tested, several "walleroos" would not retract to the closed position. They are located in the patient care areas near rooms 403, 404, 405, & 406.

This deficient practice was confirmed by the Facilities Services Manager at the time of inspection.

Based on observations, the facility had oxygen storage not meeting the requirements of NFPA 99. This deficient practice could affect all residents, staff and visitors.

Findings include:

During the facility tour on 10-30-12 at 2:30 PM, it was observed that the required exhaust from the medical gas storage room on the second floor does not go into a one hour rated shaft.

This deficient practice was confirm by the Facility Services Manager at the time of inspection.

Based on observation and interview, the facility oxygen storage area(S) did not have the proper signage in accordance with 19.3.2.4, NFPA, 8.6.4.2.

Findings include:

During the facility tour on 10-30-12 at 1:00 PM it was observed that not all locations where oxygen is being stored are labeled as "NO SMOKING".

This deficient practice was confirmed by the Facility Services Manager at the time of inspection.