HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain the 1-hour fire rated wall construction between the egress corridor and the electrical room. It is essential that walls required to be of 1-hour fire rated construction be maintained so that in the event of a fire, the walls would prevent the spread of smoke and/or fire to and from other areas of the facility. This deficient practice has the potential to harm all patients, staff, outpatients and occupants who use the corridor. The findings are:

A. On 4/7/2011 at 11:00 AM, during a tour of the 1st floor, the surveyor observed the fire blocking material was missing or pushed away from the space around an electrical conduct. Therefore, not maintaining the required 1-hour fire rating of the wall located between the corridor and the Engineering Electrical Room near the boiler room.
1. During an interview on 4/7/2011 with the Facility Manager and Maintenance Supervisor it was said that the building must have experienced movement when the kitchen floor was being removed.
B. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
C. The Administrator and other hospital staff were notified of this finding at the exit conference on 4/7/2011 at 3:30 PM.

Based on observation and staff interview, the facility failed to ensure doors located in patient corridors were capable of resisting the passage of smoke. It is essential that doors provided with self closing devices are maintained so that in the event of a fire, these doors would prevent the spread of smoke and/or fire to and from other areas of the facility. This deficient practice has the potential to harm patients, staff, and occupants who use the 3rd floor corridor. The findings are:

A. On 4/5/2011 between 8:00 AM - 5:30 PM, during a tour of the 3rd floor with the Facility Manager and Maintenance Supervisor, the surveyor observed the four holes at the top of the Clean Utility room door. Therefore, compromising the door ability to resist the passage of smoke between the Clean Utility room and the corridor located on the 3rd floor.
1. During interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor, it was said the closing device must have been replaced with a new one.
B. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
C. The Administrator and other hospital staff were notified of the above findings at the exit conference on 4/7/2011 at 3:30 PM.

Based on observation and staff interview, the facility failed to ensure mechanical room walls required to be of 1-hour fire rated construction are maintained so that in the event of a fire these walls would prevent the spread of smoke and/or fire to and from other areas of the facility. This deficient practice has the potential to harm patients, staff, and occupants who use the 3rd floor corridor. The findings are:

A. On 4/5/2011 between 8:00 AM - 5:30 PM, during a tour of the 3rd floor with the Facility Manager and Maintenance Supervisor, the surveyor observed one (1) layer of drywall missing from the mechanical room's west wall located near the electrical conduit and electrical outlet. Therefore, compromising the wall's ability to resist the passage of fire and/or smoke between the mechanical room and the patient area located on the 3rd floor.
1. During interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor, it was said the wall would be repaired.
B. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
C. The Administrator and other hospital staff were notified of the above findings at the exit conference on 4/7/2011 at 3:30 PM.

Reference NFPA 13
Section 1-5.1 Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

Reference: NFPA 13, Sect. 1-6.1 states that a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.


Based on observation and interview, the facility failed to ensure automatic sprinkler systems were properly maintained and free of lint in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems) and NFPA 13 (Standard for the Installation of Sprinkler Systems). This deficient practice had the potential to affect all staff, patients and occupants within the Behavioral Unit Laundry and a closet in the Admitting area. The findings are:


A. On 4/5/2011 at 5:00 PM, during a tour of the Behavioral Unit located in the "Pavilion", the surveyor observed a build up of lint on the sprinkler head located in the laundry room. This lint build up would alter the response characteristics of the sprinkler head. This would result in delayed response or an altered spray pattern in the event of a fire.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said the sprinkler head would be reported to housekeeping and would have it taken care of.
B. On 4/7/2011 at 8:30 AM, during a tour of the Admitting Office area, the surveyor observed a sprinkler head was not provided in the small closet behind the reception.
1. During an interview on 4/7/2011 with the Facility Manager and Maintenance Supervisor said they were not sure why the sprinkler head was missing, but it would be corrected.
C. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
D. The Administrator and other hospital staff were notified of this finding at the exit conference on 4/7/2011 at 3:30 PM.

Based on observation, testing and staff interview, the facility failed to assure the mechanical ventilation is installed and is operational within all required areas to include janitors closets. This deficient practice has the potential to harm all staff working within janitors closets. The findings are:

A. On 4/5/2011 between 8:00 AM - 5:30 PM, during a tour of the 3rd floor with the Facility Manager and Maintenance Supervisor, the surveyor observed when tested the Janitor's Closet room ventilation was not working.
1. During interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor, it was said they would look into it (the ventilation for this room).
B. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
C. The Administrator and other hospital staff were notified of the above findings at the exit conference on 4/7/2011 at 3:30 PM.

Based on observation and staff interview, the facility failed to ensure means of egress corridors were maintained free of obstructions and impediments to full instant use which resulted in equipment and items left unattended in the 3rd floor, 4 th floor, Outpatient OR Holding corridors and Outpatient pre/post-op. This deficient practice has the potential to harm all patients, staff, outpatients and occupants who use the corridors in the event these corridors need to be used as emergency egress during fire or other emergency. The findings are:

A. On 4/5/2011 at 8:30 AM, during a tour of the 4 th floor, the surveyor observed an X-ray view box mounted to the corridor wall on that extended 6 inches into the corridor.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said that the 4 th floor was not in use and the hospital was planning a remodel in future. Therefore, the box could be removed.
B. On 4/5/2011 at 8:50 AM, during a tour of the 3 th floor, the surveyor observed a small scale, 2 IV poles, a 4-foot wide wheelchair, and box at the west end of the corridor near rooms 318 and 319 that reduced the clear width of the corridor from 8 feet wide to 4 feet and a "cow" recharging in front of the writing surface at the nurse station.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said these items would be relocated and the writing surface would be modified to discourage objects left in the corridor.
C. On 4/6/2011 at 10:30 AM, during a tour of the Outpatient pre/post-op unit, the surveyor observed wheelchairs, a patient stretcher, and a scale placed in front of the restroom near the nurse station in the exit access path.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said these items would be relocated.
D. On 4/6/2011 at 10:30 AM, during a tour of the Outpatient OR Holding corridor, the surveyor observed a patient stretcher and a table with boxes of masks and booties.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said these items were used by the OR staff for gowning, but they would relocate them into the main OR pre/post-op room.
E. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
F. The Administrator and other hospital staff were notified of this finding at the exit conference on 4/7/2011 at 3:30 PM.

Based on observation and staff interview, the facility failed to maintain the 1-hour fire rated wall construction between the egress corridor and the electrical room. It is essential that walls required to be of 1-hour fire rated construction be maintained so that in the event of a fire, the walls would prevent the spread of smoke and/or fire to and from other areas of the facility. This deficient practice has the potential to harm all patients, staff, outpatients and occupants who use the corridor. The findings are:

A. On 4/7/2011 at 11:00 AM, during a tour of the 1st floor, the surveyor observed the fire blocking material was missing or pushed away from the space around an electrical conduct. Therefore, not maintaining the required 1-hour fire rating of the wall located between the corridor and the Engineering Electrical Room near the boiler room.
1. During an interview on 4/7/2011 with the Facility Manager and Maintenance Supervisor it was said that the building must have experienced movement when the kitchen floor was being removed.
B. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
C. The Administrator and other hospital staff were notified of this finding at the exit conference on 4/7/2011 at 3:30 PM.

Based on observation and staff interview, the facility failed to ensure doors located in patient corridors were capable of resisting the passage of smoke. It is essential that doors provided with self closing devices are maintained so that in the event of a fire, these doors would prevent the spread of smoke and/or fire to and from other areas of the facility. This deficient practice has the potential to harm patients, staff, and occupants who use the 3rd floor corridor. The findings are:

A. On 4/5/2011 between 8:00 AM - 5:30 PM, during a tour of the 3rd floor with the Facility Manager and Maintenance Supervisor, the surveyor observed the four holes at the top of the Clean Utility room door. Therefore, compromising the door ability to resist the passage of smoke between the Clean Utility room and the corridor located on the 3rd floor.
1. During interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor, it was said the closing device must have been replaced with a new one.
B. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
C. The Administrator and other hospital staff were notified of the above findings at the exit conference on 4/7/2011 at 3:30 PM.

Based on observation and staff interview, the facility failed to ensure mechanical room walls required to be of 1-hour fire rated construction are maintained so that in the event of a fire these walls would prevent the spread of smoke and/or fire to and from other areas of the facility. This deficient practice has the potential to harm patients, staff, and occupants who use the 3rd floor corridor. The findings are:

A. On 4/5/2011 between 8:00 AM - 5:30 PM, during a tour of the 3rd floor with the Facility Manager and Maintenance Supervisor, the surveyor observed one (1) layer of drywall missing from the mechanical room's west wall located near the electrical conduit and electrical outlet. Therefore, compromising the wall's ability to resist the passage of fire and/or smoke between the mechanical room and the patient area located on the 3rd floor.
1. During interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor, it was said the wall would be repaired.
B. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
C. The Administrator and other hospital staff were notified of the above findings at the exit conference on 4/7/2011 at 3:30 PM.

Reference NFPA 13
Section 1-5.1 Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

Reference: NFPA 13, Sect. 1-6.1 states that a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.


Based on observation and interview, the facility failed to ensure automatic sprinkler systems were properly maintained and free of lint in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems) and NFPA 13 (Standard for the Installation of Sprinkler Systems). This deficient practice had the potential to affect all staff, patients and occupants within the Behavioral Unit Laundry and a closet in the Admitting area. The findings are:


A. On 4/5/2011 at 5:00 PM, during a tour of the Behavioral Unit located in the "Pavilion", the surveyor observed a build up of lint on the sprinkler head located in the laundry room. This lint build up would alter the response characteristics of the sprinkler head. This would result in delayed response or an altered spray pattern in the event of a fire.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said the sprinkler head would be reported to housekeeping and would have it taken care of.
B. On 4/7/2011 at 8:30 AM, during a tour of the Admitting Office area, the surveyor observed a sprinkler head was not provided in the small closet behind the reception.
1. During an interview on 4/7/2011 with the Facility Manager and Maintenance Supervisor said they were not sure why the sprinkler head was missing, but it would be corrected.
C. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
D. The Administrator and other hospital staff were notified of this finding at the exit conference on 4/7/2011 at 3:30 PM.

Based on observation, testing and staff interview, the facility failed to assure the mechanical ventilation is installed and is operational within all required areas to include janitors closets. This deficient practice has the potential to harm all staff working within janitors closets. The findings are:

A. On 4/5/2011 between 8:00 AM - 5:30 PM, during a tour of the 3rd floor with the Facility Manager and Maintenance Supervisor, the surveyor observed when tested the Janitor's Closet room ventilation was not working.
1. During interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor, it was said they would look into it (the ventilation for this room).
B. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
C. The Administrator and other hospital staff were notified of the above findings at the exit conference on 4/7/2011 at 3:30 PM.

Based on observation and staff interview, the facility failed to ensure means of egress corridors were maintained free of obstructions and impediments to full instant use which resulted in equipment and items left unattended in the 3rd floor, 4 th floor, Outpatient OR Holding corridors and Outpatient pre/post-op. This deficient practice has the potential to harm all patients, staff, outpatients and occupants who use the corridors in the event these corridors need to be used as emergency egress during fire or other emergency. The findings are:

A. On 4/5/2011 at 8:30 AM, during a tour of the 4 th floor, the surveyor observed an X-ray view box mounted to the corridor wall on that extended 6 inches into the corridor.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said that the 4 th floor was not in use and the hospital was planning a remodel in future. Therefore, the box could be removed.
B. On 4/5/2011 at 8:50 AM, during a tour of the 3 th floor, the surveyor observed a small scale, 2 IV poles, a 4-foot wide wheelchair, and box at the west end of the corridor near rooms 318 and 319 that reduced the clear width of the corridor from 8 feet wide to 4 feet and a "cow" recharging in front of the writing surface at the nurse station.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said these items would be relocated and the writing surface would be modified to discourage objects left in the corridor.
C. On 4/6/2011 at 10:30 AM, during a tour of the Outpatient pre/post-op unit, the surveyor observed wheelchairs, a patient stretcher, and a scale placed in front of the restroom near the nurse station in the exit access path.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said these items would be relocated.
D. On 4/6/2011 at 10:30 AM, during a tour of the Outpatient OR Holding corridor, the surveyor observed a patient stretcher and a table with boxes of masks and booties.
1. During an interview on 4/5/2011 with the Facility Manager and Maintenance Supervisor it was said these items were used by the OR staff for gowning, but they would relocate them into the main OR pre/post-op room.
E. On 4/4/2011, during a tour of the facility with the hospital staff, the DON provided a license capacity of 201 and a census of 31.
F. The Administrator and other hospital staff were notified of this finding at the exit conference on 4/7/2011 at 3:30 PM.