HospitalInspections.org

Based on observations, it was determined that the facility failed to maintain the corridor doors.

The findings include:

Observation on 7/26/11 at 9:57 AM, revealed the fire door in the emergency room waiting area would not close within the door frame.

This findings were acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to maintain the hazardous areas..

The findings include:

Observation on 7/26/11 at 10:11 AM, revealed the laboratory door was missing automatic door closure.

The finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to maintain exit access.

The findings include:

Observation on 7/26/11 at 9:29 AM, revealed the generator switch room's exit was obstructed by an installed window style air conditioning unit, that limits the swing of the exit door.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on records review, it was determined that the facility failed to conduct the required fire drills.

The findings include:

Records review on 7/26/11 at 10:50 AM, revealed the facility failed to conduct the 2nd quarter, second shift firr 2010.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to maintain the fire alarm system.

The findings include:


1. Observation on 7/26/11 at 10:16 AM, revealed above the ceiling at the medical surgical corridor doors, fire alarm wires were spliced and not secured in a junction box.

2. Testing of the fire alarm system on 7/26/11 at 9:15 AM, revealed the fire alarm remote annunciation panel did not receive a trouble alarm when the monitoring station communication wire was disconnected.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on records review, it was determined that the facility failed to maintain the smoke detector.

The findings include:

Document review on 7/26/11 at 10:45 AM, revealed the facility failed to provide documentation for the smoke detector sensitivity test.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations and record review, it was determined that the facility failed to maintain automatic sprinkler system.

The findings include:
Observation during a tour of the facility and document review on 7/26/11 revealed the following.

1. AT 9:00 AM, the fire department connection adjacent to the bio-hazard storage room was missing the FDC sign.

2. AT 9:03 AM, the facilities main fire department connection located behind the nursing home was missing the FDC sign.

3. At 9:38 AM, a sprinkler pipe was leaking in the kitchen's cooler #3.

4. At 10:40 AM, during record record review, the facility was unable to provide documentation of the sprinkler system 5 year obstruction investigation.

These findings were acknowledged by the administrator and Maintenance Supervisor at the exit conference 7/26/11.

Based on observations, it was determined that the facility failed to maintain heating, ventilating and air conditionings.

The findings include:

Observation on 7/26/11 at 10:06 AM, revealed the laboratory did not maintain negative pressure.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/18/11.

Based on kitchen staff interviews, it was determined that the facility failed to protect the cooking facilities.

The findings include:

Interview of kitchen staff members #1 and #2 on 7/26/11 at 9:48 AM revealed the staff did not know the facilities fire response policy nor how to activate the kitchen hood suppression system.


This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to maintain the means of egress free of all obstructions.

The findings include:

Observation of the facility on 7/26/11 at 10:00AM, revealed beds stored in the egress path near the maintenance office.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to properly store oxygen cylinders.

The findings include:

Observation of the facility on 7/26/11 at 10:26AM, revealed oxygen cylinders being stored in a non-vented storage room in the 200 Hallway.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Penetrations and miscellaneous openings in fire barriers such as pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.

Based on observations, it was determined that the facility failed to maintain the fire barriers.

The findings include:

1. Observation during a tour of the facility on 7/26/11 at 9:40 AM, revealed fire barrier located above the drop ceiling had penetrations throughout the facility.

2. Observation on 7/26/11 at 10:13 AM, revealed the stairway at admitting office had a crack in the fire wall.

These finding were acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to properly store flammable and combustible liquids.

The findings include:

Observation during a tour of the facility on 7/26/11 at 9:00 AM, revealed excessive flammible liquids and aersols improperly stored in the maintenance office.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to maintain the corridor doors.

The findings include:

Observation on 7/26/11 at 9:57 AM, revealed the fire door in the emergency room waiting area would not close within the door frame.

This findings were acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to maintain the hazardous areas..

The findings include:

Observation on 7/26/11 at 10:11 AM, revealed the laboratory door was missing automatic door closure.

The finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to maintain exit access.

The findings include:

Observation on 7/26/11 at 9:29 AM, revealed the generator switch room's exit was obstructed by an installed window style air conditioning unit, that limits the swing of the exit door.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on records review, it was determined that the facility failed to conduct the required fire drills.

The findings include:

Records review on 7/26/11 at 10:50 AM, revealed the facility failed to conduct the 2nd quarter, second shift firr 2010.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to maintain the fire alarm system.

The findings include:


1. Observation on 7/26/11 at 10:16 AM, revealed above the ceiling at the medical surgical corridor doors, fire alarm wires were spliced and not secured in a junction box.

2. Testing of the fire alarm system on 7/26/11 at 9:15 AM, revealed the fire alarm remote annunciation panel did not receive a trouble alarm when the monitoring station communication wire was disconnected.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on records review, it was determined that the facility failed to maintain the smoke detector.

The findings include:

Document review on 7/26/11 at 10:45 AM, revealed the facility failed to provide documentation for the smoke detector sensitivity test.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations and record review, it was determined that the facility failed to maintain automatic sprinkler system.

The findings include:
Observation during a tour of the facility and document review on 7/26/11 revealed the following.

1. AT 9:00 AM, the fire department connection adjacent to the bio-hazard storage room was missing the FDC sign.

2. AT 9:03 AM, the facilities main fire department connection located behind the nursing home was missing the FDC sign.

3. At 9:38 AM, a sprinkler pipe was leaking in the kitchen's cooler #3.

4. At 10:40 AM, during record record review, the facility was unable to provide documentation of the sprinkler system 5 year obstruction investigation.

These findings were acknowledged by the administrator and Maintenance Supervisor at the exit conference 7/26/11.

Based on observations, it was determined that the facility failed to maintain heating, ventilating and air conditionings.

The findings include:

Observation on 7/26/11 at 10:06 AM, revealed the laboratory did not maintain negative pressure.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/18/11.

Based on kitchen staff interviews, it was determined that the facility failed to protect the cooking facilities.

The findings include:

Interview of kitchen staff members #1 and #2 on 7/26/11 at 9:48 AM revealed the staff did not know the facilities fire response policy nor how to activate the kitchen hood suppression system.


This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to maintain the means of egress free of all obstructions.

The findings include:

Observation of the facility on 7/26/11 at 10:00AM, revealed beds stored in the egress path near the maintenance office.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to properly store oxygen cylinders.

The findings include:

Observation of the facility on 7/26/11 at 10:26AM, revealed oxygen cylinders being stored in a non-vented storage room in the 200 Hallway.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Penetrations and miscellaneous openings in fire barriers such as pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.

Based on observations, it was determined that the facility failed to maintain the fire barriers.

The findings include:

1. Observation during a tour of the facility on 7/26/11 at 9:40 AM, revealed fire barrier located above the drop ceiling had penetrations throughout the facility.

2. Observation on 7/26/11 at 10:13 AM, revealed the stairway at admitting office had a crack in the fire wall.

These finding were acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.

Based on observations, it was determined that the facility failed to properly store flammable and combustible liquids.

The findings include:

Observation during a tour of the facility on 7/26/11 at 9:00 AM, revealed excessive flammible liquids and aersols improperly stored in the maintenance office.

This finding was acknowledged by the Administrator and verified by Maintenance Supervisor at the exit conference on 7/26/11.