HospitalInspections.org

1. Based on observation, the facility had penetrations in the ceiling/walls for two (2) of six (6) observations.

The findings included:

A. It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that there were ceiling penetrations found in the following locations:

a) Auditorium
b) Teledata closet in the auditorium

B. It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that ceiling tiles were missing in three (3) of four (4) areas observed. The areas included:

a) Outside room 156.1
b) Room 258
c) Room 1E67

1. Based on observation, the facility doors do not close flush and latch in frame for six (6) of twenty (20) observed.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the doors in the following areas did not close flush and latch in frame.

a) Door 107 in cafeteria
b) Egress door109.02
c) Door 1305 soiled linen closet
d) Door 1B06
e) Door 2A03
f) Door 2A66

2. Based on observation, the facility doors were disengaged in three (4) of 10.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the doors in the following areas were disengaged.

a) Door 109.6 electrical closet
b) Separation door next to room 156.1
c) Door 1MEL2
d) IT1 closet
e) 1EL5 closet
f) Door 2D13


3. Based on observation, the facility door did not open in one (1) of four (4) observations.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the exit door 1F31 did not open.

4. Based on observation, a facility door was missing hardware in one (1) of one (1) observation.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, door 191 Teledata room was missing it ' s hardware.

5. Based on observation, a facility door was not operable in one (1) of one (1) observation.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that 2B exit stairwell door lock is not operable.

6. Based on observation, the facility door was being held open with improper hold open device one (1) of ten (10) observations.
The findings include:
It was observed at approximately 10:00am through 2:00pm on July 29, 2014, room 237 and 205 was held open with improper hold open device.

Based on observation, the facility spare sprinkler head box had one (1) of one (1) spare sidewall head.

The findings include:

NFPA 136.2.9.1 Stock of Spare Sprinklers states, "A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced"

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the facility had one spare sidewall sprinkler head in the sidewall sprinkler head box.

1. Based on observation, the facility fire extinguisher was not on a hanger in one (1) of ten (10) observations.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the portable fire extinguisher was not on a hanger. The fire extinguisher was observed stored on rhe floor surface.

2. Based on observation, the facility fire extinguishers had not had annual service in one hundred (100) of one hundred 100 observations.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that the facility fire extinguishers annual service had expired.

2000 LIFE SAFETY CODE-LSC 4.5.3.2

Unobstructed Egress

In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed.

1. Based on observation, the exit door was obstructed in two (2) of two (2) observations.

The findings include:

a) It was observed at approximately 10:00am through 2:00pm on July 29, 2014, room 164 exit door was obstructed by a cabinet.
b) It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the secondary exit was obstructed by sandbags.

2000 LIFE SAFETY CODE- LSC 4.5.7
Maintenance
Whenever or wherever any device, equipment,
system, condition, arrangement level of
protection, or any other feature is required for
compliance with the provisions of this Code,
such device, equipment, system, condition,
arrangement, level of protection, or other feature
shall thereafter be maintained unless the Code
exempts such maintenance.


2. Based on observation, the facility kitchen hood and duct suppression system was not in service in one (1) of one (1) observation at the six month interval as required by NFPA 101.9.2.3 in accordance with NFPA 96 and NFPA 96 (98), sec.8-3.1.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014 to July 30, 2014, the kitchen hood and duct system had not been service since September 2013.

2000 LIFE SAFETY CODE-LSC 4.5.1 Multiple
Safeguards
The design of every building or structure intended
for human occupancy shall be such that reliance
for safety to life does not depend solely on any
single safeguard. An additional safeguard (s)
shall be provided for life safety in case any single
safeguard is ineffective due to inappropriate
human actions or system failure.

3. Based on observation, the facility has storage stored directly on the floor in nine (9) of fifteen (15 instances.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014 to July 30, 2014, the following areas had storage stored directly on the floor:

a) Room 242
b) Room 243
c) Room 2B11
d) Room 233
e) Room 216 penthouse
f) Stairwell #20 inside penthouse
g) Room 185.03
h) Room 167.10
i) Room 1D

4. Based on observation, the facility rooms are missing identification labels in four (4) of four (4).

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014 to July 30, 2014, identification labels were missing in the following areas:

a) Room 1E72
b) Room 1E71.0
c) Room 1E69
d) Room 2D70

Based on observation, the facility has exposed wiring in one (1) of 1 in the teledata closet.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that teledata closet IT2 has an open junction box with exposed wiring.

1. Based on observation, the facility had penetrations in the ceiling/walls for two (2) of six (6) observations.

The findings included:

A. It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that there were ceiling penetrations found in the following locations:

a) Auditorium
b) Teledata closet in the auditorium

B. It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that ceiling tiles were missing in three (3) of four (4) areas observed. The areas included:

a) Outside room 156.1
b) Room 258
c) Room 1E67

1. Based on observation, the facility doors do not close flush and latch in frame for six (6) of twenty (20) observed.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the doors in the following areas did not close flush and latch in frame.

a) Door 107 in cafeteria
b) Egress door109.02
c) Door 1305 soiled linen closet
d) Door 1B06
e) Door 2A03
f) Door 2A66

2. Based on observation, the facility doors were disengaged in three (4) of 10.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the doors in the following areas were disengaged.

a) Door 109.6 electrical closet
b) Separation door next to room 156.1
c) Door 1MEL2
d) IT1 closet
e) 1EL5 closet
f) Door 2D13


3. Based on observation, the facility door did not open in one (1) of four (4) observations.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the exit door 1F31 did not open.

4. Based on observation, a facility door was missing hardware in one (1) of one (1) observation.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, door 191 Teledata room was missing it ' s hardware.

5. Based on observation, a facility door was not operable in one (1) of one (1) observation.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that 2B exit stairwell door lock is not operable.

6. Based on observation, the facility door was being held open with improper hold open device one (1) of ten (10) observations.
The findings include:
It was observed at approximately 10:00am through 2:00pm on July 29, 2014, room 237 and 205 was held open with improper hold open device.

Based on observation, the facility spare sprinkler head box had one (1) of one (1) spare sidewall head.

The findings include:

NFPA 136.2.9.1 Stock of Spare Sprinklers states, "A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced"

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the facility had one spare sidewall sprinkler head in the sidewall sprinkler head box.

1. Based on observation, the facility fire extinguisher was not on a hanger in one (1) of ten (10) observations.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the portable fire extinguisher was not on a hanger. The fire extinguisher was observed stored on rhe floor surface.

2. Based on observation, the facility fire extinguishers had not had annual service in one hundred (100) of one hundred 100 observations.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that the facility fire extinguishers annual service had expired.

2000 LIFE SAFETY CODE-LSC 4.5.3.2

Unobstructed Egress

In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed.

1. Based on observation, the exit door was obstructed in two (2) of two (2) observations.

The findings include:

a) It was observed at approximately 10:00am through 2:00pm on July 29, 2014, room 164 exit door was obstructed by a cabinet.
b) It was observed at approximately 10:00am through 2:00pm on July 29, 2014, the secondary exit was obstructed by sandbags.

2000 LIFE SAFETY CODE- LSC 4.5.7
Maintenance
Whenever or wherever any device, equipment,
system, condition, arrangement level of
protection, or any other feature is required for
compliance with the provisions of this Code,
such device, equipment, system, condition,
arrangement, level of protection, or other feature
shall thereafter be maintained unless the Code
exempts such maintenance.


2. Based on observation, the facility kitchen hood and duct suppression system was not in service in one (1) of one (1) observation at the six month interval as required by NFPA 101.9.2.3 in accordance with NFPA 96 and NFPA 96 (98), sec.8-3.1.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014 to July 30, 2014, the kitchen hood and duct system had not been service since September 2013.

2000 LIFE SAFETY CODE-LSC 4.5.1 Multiple
Safeguards
The design of every building or structure intended
for human occupancy shall be such that reliance
for safety to life does not depend solely on any
single safeguard. An additional safeguard (s)
shall be provided for life safety in case any single
safeguard is ineffective due to inappropriate
human actions or system failure.

3. Based on observation, the facility has storage stored directly on the floor in nine (9) of fifteen (15 instances.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014 to July 30, 2014, the following areas had storage stored directly on the floor:

a) Room 242
b) Room 243
c) Room 2B11
d) Room 233
e) Room 216 penthouse
f) Stairwell #20 inside penthouse
g) Room 185.03
h) Room 167.10
i) Room 1D

4. Based on observation, the facility rooms are missing identification labels in four (4) of four (4).

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014 to July 30, 2014, identification labels were missing in the following areas:

a) Room 1E72
b) Room 1E71.0
c) Room 1E69
d) Room 2D70

Based on observation, the facility has exposed wiring in one (1) of 1 in the teledata closet.

The findings include:

It was observed at approximately 10:00am through 2:00pm on July 29, 2014, that teledata closet IT2 has an open junction box with exposed wiring.