HospitalInspections.org

K-161
Based on observation and interview with facility staff, the facility failed to ensure materials used to maintain building construction type requirements are poorly maintained. In the event of a fire in the effected areas all residents and staff may be affected.

Reference: NFPA 101 2012 Ed. Sec.19.1.6.1 thru 19.6.7

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed spray on fireproofing used to maintain the structual framing rating is missing in the 3rd floor mechanical room.

Staff member M confirmed the findings at the time of discovery.

K-161
Based on observation and interview with facility staff, the facility failed to ensure the facility meets construction type requirements. This could affect all patients and staff in an emergency.

Reference: NFPA 101 2012 Ed. Sec.19.1.6.1 thru 19.6.7

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed the spray on fireproofing on the ceiling is missing in several areas.

Staff member M confirmed the findings at the time of discovery.

K 222
Based on observation and interview with facility staff, the facility failed to ensure 1 of several doors in the building is provided with only one lock or latch.

Reference: NFPA 101 2012 Ed. Sec 19.2.2.2.4

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed the 3rd floor toilet room on the South hallway has multiple locks and latches.

Staff member M confirmed the findings at the time of discovery.

K 232
Based on observation and interview with facility staff, the facility failed to ensure corridors are not being used for combustible storage. In the event of a fire in the affected area, all clients and staff may be affected.

Reference: NFPA 101 2012 Ed. Sec. 19.2.3.4

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed a combustible wooden storage crate being stored in the radiology corridor.
Staff member M confirmed the findings at the time of discovery.

K 293
Based on observation and interview with facility staff, the facility failed to ensure exits on one of 5 floors are properly marked. Staff and clients in the affected area may be affected.

Reference: NFPA 101 2012 Ed. Sec. 7.10, 19.2.10.1

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed an exit sign is missing in the 1st floor administration area and the exit is not marked.

Staff member M confirmed the findings at the time of discovery.

K 311
Based on observation and interview with facility staff, the facility failed to ensure 1 of 2 vertical openings were properly maintained. In the event of a fire in the affected area all clients and staff may be affected.

Reference: NFPA 101 2012 Ed. Sec. 19.3.1.1 thru 19.3.1.6

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed openings in the one hour elevator shaft that was intended for a second door were filled in with gypsum and the joint between th gypsum and the block walls were not sealed with approved fire stopping.

Staff member M confirmed the findings at the time of discovery.

K 311
Based on observation and interview with facility staff, the facility failed to ensure penetrations in one of several vertical openings are properly fire stopped.

Reference: NFPA 101 2012 Ed. Sec. 19.3.1.1 thru 19.3.1.6

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed penetrations in the NW stairwell were not fire stopped with approved material.

Staff member M confirmed the findings at the time of discovery.

K-311
Based on observation and interview with facility staff, the facility failed to ensure all vertical penetrations are sealed with an approved fire stop material.

Reference: NFPA 101 2012 Ed. Sec. 19.3.1.1 thru 19.3.1.6

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed numerous vertical penetrations were not sealed with an approved fire stop material:
1) Three vertical pipe penetrations in room H550.
2) Two vertical pipe penetrations in room H656

Staff member M confirmed the findings at the time of discovery.

K 341
Based on observation and interview with facility staff, the facility failed to ensure proper fire alarm visual notification is provided. In the event of a fire all hearing impaired staff and clients may be affected.

Reference: NFPA 101 2012 Ed. Sec. 9.6, 19.3.4.1

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed fire alarm strobes were set at the incorrect candela or not spaced correctly in the following areas:
(a) The wall mounted strobe in the corridor is set at 110 cd
(b) There was no strobe provided in the men ' s locker room on the second floor.
(c) There was no strobe provided in the second floor recovery room.
(d) There was no strobe provided in the contaminated instrument elevator lobby .
(e) There was no strobe provided in the doctors dictation room on the second floor.
(f) There was no strobe provided in the anesthesia office.
(g) Proper spacing of strobes is not maintained in the ASC lobby and consultation space.

Staff member M confirmed the findings at the time of discovery.

Based on observation and interview with facility staff, the facility failed to ensure all areas of the building have complete sprinkler coverage. In the event of a fire in these areas, all clients and staff may be affected.

Reference: NFPA 101 2012 Ed. Sec. 9.7.1.1, 19.3.5.3, 19.3.5.5

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed the following areas that were not completely covered with sprinkler protection:
(a) Sprinkler coverage was obstructed by a 5 foot HVAC duct in the basement boiler room.
(b) Two sprinkler heads were removed and branch lines plugged in the basement boiler room.
(c) A pendant sprinkler head was concealed above a light fixture lens outside room M-282
(d) Sprinklers were spaced more than 7 feet 6 inches apart at the storage alcove on the back hall of NNICU
(e) The outside trash collection area is covered by a canopy and is being used for storage and the area is not provided with sprinkler protection.
(f) The freezer in the main kitchen is not provided with sprinkler protection.

Staff member M confirmed the findings at the time of discovery.

K 351
Based on observation and interview with facility staff, the facility failed to ensure all areas of the building have complete sprinkler coverage. In the event of a fire in these areas, all clients and staff may be affected.

Reference: NFPA 101 2012 Ed. Sec. 9.7.1.1, 19.3.5.3, 19.3.5.5

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed the following areas that were not completely covered with sprinkler protection:
(a) Sprinkler coverage was obstructed by a 5 foot HVAC duct in the basement boiler room.
(b) Two sprinkler heads were removed and branch lines plugged in the basement boiler room.
(c) A pendant sprinkler head was concealed above a light fixture lens outside room M-282
(d) Sprinklers were spaced more than 7 feet 6 inches apart at the storage alcove on the back hall of NNICU
(e) The outside trash collection area is covered by a canopy and is being used for storage and the area is not provided with sprinkler protection.
(f) The freezer in the main kitchen is not provided with sprinkler protection.

Staff member M confirmed the findings at the time of discovery.

K 351
Based on observation and interview with facility staff, the facility failed to ensure sprinkler were properly installed in two areas of the building. In the event of a fire in the affected areas all staff and clients may be affected should the system fail or not function properly.

Reference: NFPA 101 2012 Ed. Sec. 9.7.1.1, 19.3.5.3 thru 19.3.5.5

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed the sprinkler in Procedure room 5 is 8 feet off the wall and the lower ceiling at the nurses station of Neighborhood 3 is within 18 inches of the pendant head sprinklers deflectors.

Staff member M confirmed the findings at the time of discovery.

K 353
Based on observation and interview with facility staff, the facility failed to ensure proper testing and maintenance of sprinklers has been conducted. Staffing may be affected by a fire in the affected area.

Reference: NFPA 101 2012 Ed. Sec. 9.7.6 NFPA 25 2011 Ed.

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed sprinkler heads in the basement boiler room are over 50 years old.

Staff member M confirmed the findings at the time of discovery

K 353
Based on observation and interview with facility staff, the facility failed to ensure sprinkler piping is properly maintained and failed to ensure the correct types of sprinklers are used in isolated areas. Should the system fail in the event of a fire all clients and staff may be affected.

Reference: NFPA 101 2012 Ed. Sec. 9.7.6 NFPA 25 2011 Ed.

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed HVAC and plumbing pipes are suspended form the sprinkler pipes in the Southwest stair and sprinklers are mixed use throughout the ground floor hallway. Some sprinklers were standard response and others were quick response. The sprinkler in the clean supply room on the 4th floor was loaded with debris.

Staff member M confirmed the findings at the time of discovery.

K 372
Based on observation and interview with facility staff, the facility failed to ensure the smoke barrier on one of five floors is properly maintained. In the event of a fire on that floor, the clients and staff of that floor may be affected.

Reference: NFPA 101 2012 Ed. Sec. 8.6.7.1 (1), 19.3.7.3

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed the smoke barrier adjacent to the center stairs on the 3rd floor has penetrations that are not properly fire stopped.

Staff member M confirmed the findings at the time of discovery.

K-372
Based on observation and interview with facility staff, the facility failed to ensure all penetrations in fire and smoke barrier walls were sealed with an approved fire stop material.

Reference: NFPA 101 2012 Ed. Sec. 8.6.7.1 (1), v19.3.7.3

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed penetrations were present in both one and two hour fire and smoke barrier walls:
1) Above the ceiling across the hall from room HL10.
2) Above room H256A on the second floor
These findings were confirmed by staff M at the time of discovery.

K 521
Based on observation and interview with facility staff, the facility failed to ensure gas fired appliances and rooms containing gas fired appliances are properly ventilated.

Reference: NFPA 101 2012 Ed. Sec. 9.2, 19.5.2.1

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed there were not high and low vents for combustion and ventilation air in the EVS laundry room. Observation also revealed the dryer vents in the EVS room are leaking above the acoustical ceiling and the joints in the metal dryer ducts are secured together using sheet metal screws.

Staff member M confirmed the findings at the time of discovery.

K-911
Based on observation and interview with facility staff, the facility failed to ensure electrical systems are not in accordance with NFPA 99.

Reference: NFPA 70 2011 Ed.

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed the circuit breakers in the electrical panel boxes were not identified.

Staff member M confirmed the findings at the time of discovery.

K 920
Based on observation and interview with facility staff, the facility failed to ensure power strips were properly installed in the administration area of one of nine floors. Improper installation of these devices may affect the staff and clients in that area.

Reference: NFPA 70 2011 Ed. 590.3 (D)

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed the power strips were resting on the floor of the 3rd floor administration area.

Staff member M confirmed the findings at the time of discovery.

K 920
Based on observation and interview with facility staff, the facility failed to ensure power strips were properly installed in the administration area of one of nine floors. Improper installation of these devices may affect the staff and clients in that area.

Reference: NFPA 70 2011 Ed. Sec. 590.3 (d)

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed the power strips were resting on the floor of the 3rd floor administration area.

Staff member M confirmed the findings at the time of discovery.

K 923
Based on observation and interview with facility staff, the facility failed to ensure oxygen cylinders are properly secured on 3 of 9 floors. In the event of the cylinders falling all residents and clients may be affected.

Reference: NFPA 99 2012 Ed. Sec. 11.3.3.3

Findings Include:
On 12/12/2016 between 10:30 a.m. and 5:30 p.m. observation revealed oxygen cylinders in the hall next to the elevators on the 7th, 8th, and 9th floors are not secured.

Staff member M confirmed the findings at the time of discovery.