HospitalInspections.org

Based on observation, interview, and document review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation on 12/10/14 revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 11/02/10 confirmed the above condition.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain corridor separation from use areas by walls with at least a 30 minute fire resistance rating at the sump pump/tunnel crawl space room in the basement (an air transfer grille opening was installed in the wall adjacent to the room door). Findings include:

1. Observation at 1:45 p.m. on 12/11/14 revealed an air transfer grille opening (approximately 10 inches by 10 inches) had been installed in the corridor wall for the sump pump/tunnel crawl space room in the basement. The opening was adjacent to the corridor door of the room and was equipped with a combination fire/smoke damper. Transfer grilles are not acceptable installations in exit corridor walls. Interview with the director of plant operations at the time of the observation confirmed those findings. He stated the transfer grille had been installed to have the tunnel negative air pressure draw unpleasant odors from the sump room.

This deficiency affects one component of the requirements for corridor wall construction.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas for the elevator hydraulic room in the basement. The ceiling of the one-hour fire-rated hydraulic room in the basement had unsealed openings around two flexible conduit penetrations. Findings include:

1. Observation at 9:25 a.m. on 12/10/14 revealed the ceiling of the one-hour fire-rated hydraulic room in the basement had unsealed openings around two flexible conduit penetrations. Interview with the director of plant operations at the time of the observation confirmed those findings.

This deficiency affects one component of the requirements for fire-rated room locations.

Based on observation, interview, and document review, the provider failed to maintain conforming exit stairways in five randomly observed locations (south stairs, northwest stairs, east stairs, west stairs, and the north stairs). Findings include:

1. Observation on 12/10/14 at 2:15 p.m. revealed handrails were not provided on both sides of the stairwell in the south stairs and at the top of the landing of the northwest stairs. The south stairs were 39 inches wide. The northwest stairs were 50 inches wide.

2. Observation on 12/10/14 at 2:30 p.m. revealed the interior landing in front of the exterior exit door in the south stairs sloped up approximately six inches to the door threshold.

3. Observation on 12/10/14 between 2:30 p.m. and 3:00 p.m. revealed the following door openings into stair enclosures reduced the landing widths to less than 22 inches:
* The door opening into the first floor, east stairs reduced the landing to 15 inches.
* The door opening into the first floor, west stairs reduced the landing to 19 inches.
* The door opening into the first floor, north stairs reduced the landing to 17 1/2 inches.

4. Interview with the director of plant operations at the time of the above observations confirmed those findings. Review of previous survey documents dated 11/02/10 confirmed the above findings.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation, interview, and document review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation at 3:45 p.m. on 12/10/14 revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system.

Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 11/02/10 confirmed the above findings.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to install adequate combustion air for the four boilers in the boiler room. Findings include:

1. Observation at 10:30 a.m. on 12/10/14 revealed the motor control linkage was disconnected for the combustion fresh air damper for the boiler room. There was minimal air movement through the ductwork into the boiler room (when checked by hand). There was also air drawn through the crawl space into the boiler room. The damper (approximately 18 inches wide by 72 inches long) was in the closed position. Interview with the director of plant operations at the time of the observation confirmed that finding. He was unaware the damper control linkage was not in an operational condition. He stated there was a free air opening by the ground floor stair exit approximately 15 inches by 20 inches in area. This would not be adequate for the four boilers (SD 14007, SD 28818, SD 18819, and SD 28820) due to the burner British thermal unit fossil fuel input requirements.

This deficiency affects several components of the requirements for combustion fresh air.

The provider must comply with the National Fire Protection Association (NFPA 99), Standard for Health Care Facilities, section 9.4.2(A) Cylinder and Container Storage Requirements.
Based on observation and interview, the provider failed to install no smoking signs for the oxygen tank storage enclosure attached to the exterior of the building. Findings include:

1. Observation at 11:30 a.m. on 12/10/14 revealed the oxygen tank storage enclosure attached to the exterior of the building was not equipped with no smoking signs. Interview with the director of plant operations at the time of the observation confirmed that condition. He stated the enclosure had been constructed since the previous inspection in 2010. He added the 'j' size oxygen gas tanks were supplemental tanks for the liquid oxygen manifold system should it fail.

This deficiency affects one component of the requirements for oxygen storage locations.

Based on observation, interview, and document review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation on 12/10/14 revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 11/02/10 confirmed the above condition.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain corridor separation from use areas by walls with at least a 30 minute fire resistance rating at the sump pump/tunnel crawl space room in the basement (an air transfer grille opening was installed in the wall adjacent to the room door). Findings include:

1. Observation at 1:45 p.m. on 12/11/14 revealed an air transfer grille opening (approximately 10 inches by 10 inches) had been installed in the corridor wall for the sump pump/tunnel crawl space room in the basement. The opening was adjacent to the corridor door of the room and was equipped with a combination fire/smoke damper. Transfer grilles are not acceptable installations in exit corridor walls. Interview with the director of plant operations at the time of the observation confirmed those findings. He stated the transfer grille had been installed to have the tunnel negative air pressure draw unpleasant odors from the sump room.

This deficiency affects one component of the requirements for corridor wall construction.

Based on observation, testing, and interview, the provider failed to maintain proper separation of hazardous areas for the elevator hydraulic room in the basement. The ceiling of the one-hour fire-rated hydraulic room in the basement had unsealed openings around two flexible conduit penetrations. Findings include:

1. Observation at 9:25 a.m. on 12/10/14 revealed the ceiling of the one-hour fire-rated hydraulic room in the basement had unsealed openings around two flexible conduit penetrations. Interview with the director of plant operations at the time of the observation confirmed those findings.

This deficiency affects one component of the requirements for fire-rated room locations.

Based on observation, interview, and document review, the provider failed to maintain conforming exit stairways in five randomly observed locations (south stairs, northwest stairs, east stairs, west stairs, and the north stairs). Findings include:

1. Observation on 12/10/14 at 2:15 p.m. revealed handrails were not provided on both sides of the stairwell in the south stairs and at the top of the landing of the northwest stairs. The south stairs were 39 inches wide. The northwest stairs were 50 inches wide.

2. Observation on 12/10/14 at 2:30 p.m. revealed the interior landing in front of the exterior exit door in the south stairs sloped up approximately six inches to the door threshold.

3. Observation on 12/10/14 between 2:30 p.m. and 3:00 p.m. revealed the following door openings into stair enclosures reduced the landing widths to less than 22 inches:
* The door opening into the first floor, east stairs reduced the landing to 15 inches.
* The door opening into the first floor, west stairs reduced the landing to 19 inches.
* The door opening into the first floor, north stairs reduced the landing to 17 1/2 inches.

4. Interview with the director of plant operations at the time of the above observations confirmed those findings. Review of previous survey documents dated 11/02/10 confirmed the above findings.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation, interview, and document review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). Findings include:

1. Observation at 3:45 p.m. on 12/10/14 revealed the building was a three story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system.

Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 11/02/10 confirmed the above findings.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to install adequate combustion air for the four boilers in the boiler room. Findings include:

1. Observation at 10:30 a.m. on 12/10/14 revealed the motor control linkage was disconnected for the combustion fresh air damper for the boiler room. There was minimal air movement through the ductwork into the boiler room (when checked by hand). There was also air drawn through the crawl space into the boiler room. The damper (approximately 18 inches wide by 72 inches long) was in the closed position. Interview with the director of plant operations at the time of the observation confirmed that finding. He was unaware the damper control linkage was not in an operational condition. He stated there was a free air opening by the ground floor stair exit approximately 15 inches by 20 inches in area. This would not be adequate for the four boilers (SD 14007, SD 28818, SD 18819, and SD 28820) due to the burner British thermal unit fossil fuel input requirements.

This deficiency affects several components of the requirements for combustion fresh air.

The provider must comply with the National Fire Protection Association (NFPA 99), Standard for Health Care Facilities, section 9.4.2(A) Cylinder and Container Storage Requirements.
Based on observation and interview, the provider failed to install no smoking signs for the oxygen tank storage enclosure attached to the exterior of the building. Findings include:

1. Observation at 11:30 a.m. on 12/10/14 revealed the oxygen tank storage enclosure attached to the exterior of the building was not equipped with no smoking signs. Interview with the director of plant operations at the time of the observation confirmed that condition. He stated the enclosure had been constructed since the previous inspection in 2010. He added the 'j' size oxygen gas tanks were supplemental tanks for the liquid oxygen manifold system should it fail.

This deficiency affects one component of the requirements for oxygen storage locations.