HospitalInspections.org

Based on observation and record review, the provider failed to maintain a one hour fire rated protective path of egress from west stair enclosure from the second floor to the exterior of the building. Findings include:

1. Observation at 11:00 a.m. revealed the west basement stair enclosure discharged into the x-ray department on the first floor.

Observation at 11:30 p.m. revealed the west stair enclosure on the second floor discharged into the corridor of the 2001 addition.

A continuous path of escape was not provided to the exterior of the building. Review of the previous life safety code survey confirmed those conditions had existed since completion of the 2001 addition.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct the deficiencies identified at K000.

This deficiency would affect one of one smoke compartment used for patient sleeping.

Based on observation and interview, the provider failed to install a paved path of exit discharge to the public way at two exits. The exit adjacent to the kitchen on the first floor landing that ended approximately 100 feet from the nearest street. The exit from the west stair from the second floor discharged to the same landing. Findings include:

1. Observation at 9:30 a.m. on 6/9/15 revealed the exit adjacent to the kitchen on the first floor and the west stair from the second floor both discharged to the same landing that ended approximately 100 feet from a public way. Interview with the maintenance director at the time of the observations revealed the landing was part of the original construction. The provider had contracted to have a sidewalk installed within the next few days.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had the annual back-flow preventer inspection or the five year internal inspection completed in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. (See attachments.) Findings include:

1. Review of the provider's automatic sprinkler system inspection, testing, and maintenance reports at 10:00 a.m. on 6/9/15 revealed an annual inspection of the back-flow preventer had not been completed. Interview with the maintenance director at the time of the record review revealed he was unable to confirm the annual test had been completed. This deficiency could affect the safety of all patients due to fire and smoke.

Review of the provider's automatic sprinkler inspection, testing and maintenance reports at 10:00 a.m. on 6/9/15 revealed that none of the annual sprinkler system reports for the previous five years identified a five year internal inspection had been completed. Interview with the maintenance director at the time of the record review revealed he was unable to confirm that testing had ever been completed. This deficiency could affect the safety of all patients due to fire and smoke.

Based on observation and record review, the provider failed to maintain a one hour fire rated protective path of egress from west stair enclosure from the second floor to the exterior of the building. Findings include:

1. Observation at 11:00 a.m. revealed the west basement stair enclosure discharged into the x-ray department on the first floor.

Observation at 11:30 p.m. revealed the west stair enclosure on the second floor discharged into the corridor of the 2001 addition.

A continuous path of escape was not provided to the exterior of the building. Review of the previous life safety code survey confirmed those conditions had existed since completion of the 2001 addition.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct the deficiencies identified at K000.

This deficiency would affect one of one smoke compartment used for patient sleeping.

Based on observation and interview, the provider failed to install a paved path of exit discharge to the public way at two exits. The exit adjacent to the kitchen on the first floor landing that ended approximately 100 feet from the nearest street. The exit from the west stair from the second floor discharged to the same landing. Findings include:

1. Observation at 9:30 a.m. on 6/9/15 revealed the exit adjacent to the kitchen on the first floor and the west stair from the second floor both discharged to the same landing that ended approximately 100 feet from a public way. Interview with the maintenance director at the time of the observations revealed the landing was part of the original construction. The provider had contracted to have a sidewalk installed within the next few days.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system had the annual back-flow preventer inspection or the five year internal inspection completed in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. (See attachments.) Findings include:

1. Review of the provider's automatic sprinkler system inspection, testing, and maintenance reports at 10:00 a.m. on 6/9/15 revealed an annual inspection of the back-flow preventer had not been completed. Interview with the maintenance director at the time of the record review revealed he was unable to confirm the annual test had been completed. This deficiency could affect the safety of all patients due to fire and smoke.

Review of the provider's automatic sprinkler inspection, testing and maintenance reports at 10:00 a.m. on 6/9/15 revealed that none of the annual sprinkler system reports for the previous five years identified a five year internal inspection had been completed. Interview with the maintenance director at the time of the record review revealed he was unable to confirm that testing had ever been completed. This deficiency could affect the safety of all patients due to fire and smoke.