HospitalInspections.org

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that emergency lighting is provided as required.
This could place patients and staff at risk in the event of of a power outage or loss of electrical circuit.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that emergency lighting units failed to operate when tested throughout the building.
Reference: 2012 NFPA 101 CHAPTER 7 SECTION 7.9.1.2
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that additional emergency lighting is needed in corridors to provide the required level of lighting for the means of egress.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 7 SECTION 7.9.1.2

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that Exit signage is continuasly illuminated.
This could place patients and staff at risk in the event of an emergency event.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that Exit signage throughout the building failed to be illuminated on back up power.
These findings were confirmed by Staff M at the time of discovery.
Reference: NFPA 101 2012 CHAPTER 7,SECTION 7.8.2.1

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that all vertical openings were protected as required.
This could place patients and staff at risk in the event of a fire or smoke event.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that the stairwell door on 3rd floor would not close and latch properly..
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 8 SECTION 8.5.4.3

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that Hazardous areas were seperated as required.
This could place patients and staff at risk in the event of a fire.
The findings include:
1. During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a door closeing device had been removed from the rated doors for the boiler room and the main switch gear room.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 39 SECTION 39.3.2.2(1)

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that Fire Alarm System is installed with requirements of NFPA 72.
This could place patients and staff at risk in the event of a fire or smoke event.
The findings include:
1. During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that there was not a smoke detector provided over the fire alarm control panel as required.
Reference: 291 NFPA 101 CHAPTER 9 SECTION 9.6.2.8.1
2. The cross corridor does not have visual notification devices visable.
Reference: 2012 NFPA 101 SECTION 9.6.1.5 2010 NFPA 72 SECTIONS 18.5.4.4.1, 18-5.4.3, 18.5.4.4
These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that the fire alarm is installed in accordance with NFPA requirements.
This could place patients and staff at risk in the event of a fire.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that a smoke detector was not provided above the fire alarm control panel as required.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 9 SECTION 9.6.1.8.1

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that visual alarm devices could be seen from all areas as required.
This could place patients and staff at risk in the event of of a fire.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that visual alrm devices could not be seen from the cross corridors.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 9, SECTION 9.6.1.5 AND 2010 NFPA 72 , CHAPTER 18 SECTIONS 18.5.4.4.1, 18.5.4.3, 18.5.4.4

Based on observation and staff interviews it was determined the facility failed to ensure sprinkler coverage met the requirements of NFPA 13.
This could place patients and staff at risk in the event of a fire.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that sprinkler heads were not provided under duct work that is over four feet wide, in the IT Room on 5th Floor.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 Section 19.3.5.1; Chapter 9 Section 9.7.1.1(1); 2010 NFPA 13 Section 8.5.5.3.1

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that the sprinkler system was maintained as required.
This could place patients and staff at risk in the event of a fire.
The findings include:
During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that sprinkler heads throughout the building were in need of adjustment.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 9 SECTION 9.7.5, 2011 NFPA 25 CHAPTER 5 SECTION 5.2.3.1 AND 5.2.3.2

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that the sprinkler system was maintained prperly.
This could place patients and staff at risk in the event of fire.
The findings include:
During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that the gauges for the sprinkler system are over 5 years old and not labled as having been calibrated.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 9 SECTION 9.7.5, 9.7.7, 9.7.8; 2011 NFPA 25 CHAPTER 5 SECTION 5.1 TABLE 5.1.1.2

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that sprinkler system would operate properly.
This could place patients and staff at risk in the event of fire.
The findings include:
1. During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that ceiling tiles were not in place in the IT room on 6th floor.
2. During a tour of the facility with Staff M on 06/12/19 between 7:30 am and 5:00 pm observation revealed that ceiling tiles were not in place in the IT room on 4th floor.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 Chapter 19 Section 19.3.5.1 Chapter 9 Section 9.7.1.1 (1) 2010
NFPA 13 Chapter 13 Section 3.3.3

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that corridor doors latched properly.
This could place patients and staff at risk in the event of a fire.
The findings include:
1. During a tour of the facility with Staff M on 06/11/00 between 7:30 am and 5:00 pm observation revealed that Bio-hazard door on 6th floor would not latch properly.
2. During a tour of the facility with Staff M on 06/11/00 between 7:30 am and 5:00 pm observation revealed that door at 022775 on 8th floor needs to be repaired or replaced in order to close and latch properly.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 Chapter 19 sections 19.3.7.6, 19.3.7.8; Chapter 8 sections 8.5.4.3

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5.
This could place patients and staff at risk in the event of fire or smoke event.
The findings include:
1. During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a hole was noted around the sprinkler piping passing through the wall in Zone 7.
2. During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a hole was noted Enviromental Closet 8E025.
3. During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a hole was noted in Mechanical Room 8E001.
4.During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that a hole was noted in Electrical room 4J010 fourth floor.





These findings were confirmed by Staff M at the time of discovery.
Reference 2012 NFPA 101 Chapter 19, Section 19.3.7.3, Chapter 8, Section 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that corridor walls were properly rated.
This could place paitent and staff at risk in the event of a fire or smoke event.
The findings include:
During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that walls identified to the surveyor as rated walls did not go the the deck and had penetrations in them throughout the building.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 CHAPTER 8 SECTIONS 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1. & 8.5.6.2

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that rated walls were constructed as required.
This could place patients ans staff at risk in the event smoke or fire event.
The findings include:
During a tour of the facility with Staff M on 06/11/19 between 7:30 am and 5:00 pm observation revealed that walls identified to the surveyor as rated walls had the following issues throughout the building:
1. Not built to listing.
Reference 2012 NFPA 101 CHAPTER 4 SECTION 4.2.3, 4.6.12.1
2. Holes in main switch gear room walls
3. unprotected penetrations
Reference 2012 NFPA 101 CHAPTER 8 SECTIONS 8.5.6.3, AND 8.3.5
These findings were confirmed by Staff M at the time of discovery.