HospitalInspections.org

Based on review of the facility schematic, Certification of Use and Occupancy, staff interview and confirmation, the facility failed to ensure the building construction type and height met the requirements of 18.1.6.2 in regards to an unprotected wood frame. The facility capacity is 64 with a census of 64 at the time of the survey.

Findings include:

1. Review of the Certification of Use and Occupancy completed on 08/10/15 revealed a construction type of V (000). This was confirmed by Staff MM on 08/13/15 at 11:00 AM.

2. On 08/11/15 at 8:30 AM, observation of the attic space was completed and revealed unprotected wood framing and unprotected wood roofing. This was verified by Staff NN at the time of the observation.

2. Review of Building #2 drawings revealed the construction type of V (000) with no rated ceiling throughout Building #2's central space was noted on the drawings provided.

Based on observation and staff interview, the facility failed to ensure spaces open to the corridor were protected with an electronically supervised automatic smoke detection system. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of the 2000 unit lounge was noted to be open to the corridor and to not be under direct staff supervision or have an electronically supervised automatic smoke detection system.

2. Interview with Staff MM completed on 08/13/15 at 11:10 AM confirmed the lack of smoke detection in the 2000 unit lounge.

Based on Life Safety drawings, observation, and staff interview, the facility failed to ensure doors in the fire rated walls of the Southwest exit access corridor were self closing. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of the Southwest exit access corridor completed on 08/10/15 revealed the door of room 150 was noted to not have a self closing device and was open upon arrival to the area. This was confirmed by Staff MM on 08/10/15 at 1:40 PM.

Based on observation and staff interview, the facility failed to protect their hazardous areas with a one hour fire rated structure. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of room 136 (Electrical room) completed on 08/10/15 revealed multiple electrical panels and equipment producing a degree of heat. This was confirmed by Staff MM on 08/10/15 at 2:00 PM.

2. Observation above the drop ceiling of room 137 (Bathroom) completed on 08/10/15 at 2:05 PM revealed multiple penetrations in the Northeast wall and it was not sealed at the deck above. These findings were confirmed by Staff MM at the time of the observation.

3. Review of the Life Safety drawings provided by the facility revealed no one hour fire rated walls around the room 136.

Based on review of Life Safety Drawings, observation, and staff interview, the facility failed to maintain the one hour fire rated protection in the exit access corridors. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Review of the Life Safety Drawings completed on 08/10/15 revealed an exit access corridor located in the Southwest side of the building and between the new construction and the existing construction.

2. Observation of the doors in the Southwest exit access corridor completed on 08/10/15 revealed both doors and door frames from the patient care corridor to the exit access corridor were rated for 20 minutes. This was confirmed by Staff MM on 08/10/15 at 1:45 PM.

3. Observation of the doors to rooms 123, 124, 150, and 151 completed on 08/10/15 revealed 20 minute doors and door frames in the one hour wall of the Southwest exit access corridor. This was confirmed by Staff MM on 08/10/15 at 1:40 PM.

4. Observation above the drop ceiling above the exit access door in the patient care corridor outside room 125 completed on 08/10/15 revealed a 1/2 inch by 2 inch hole. This was confirmed by Staff MM on 08/10/15 at 2:40 PM.

5. Observation of the doors located in the one hour wall of the exit access corridor between the new and existing buildings completed from 08/10/15 through 08/13/15 revealed 20 minute doors and door frames, four of which had 20 minute glass panels in the doors. This was confirmed by Staff MM at the time of the observations.

6. Observation above drop ceiling above the West exit access door from the patient care area to the exit access corridor between the new building and existing building completed on 08/101/5 at 1:55 PM revealed a 6 inch water pipe with a 3/4 inch open gap and 2 half inch holes, one with 2 white and 2 gray data cables passing through. These findings were confirmed by Staff MM at the time of the observation.

7. Observation above the drop ceiling in the exit access corridor above the West exit access door from the patient care area completed on 08/10/15 at 1:57 PM revealed a 6 inch water pipe with a 3/4 inch open gap and 2 half inch holes, one with 2 white and 2 gray data cables passing through. These findings were confirmed by Staff MM at the time of the observation.

8. Observation above the drop ceiling in the exit access corridor between the new building and existing building outside room 134 completed on 08/10/15 at 2:12 PM revealed a 3/4 inch conduit penetrating the one hour wall with red data cables open on the end and a 2 inch conduit with red data cables open on the end and with open annular space. These findings were confirmed by Staff MM at the time of the observation.

9. Observation of the one hour rated wall, above the drop ceiling in room 134 completed on 08/10/15 at 2:15 PM revealed 1/2 inch hole with gray and white data cables and a 3/4 inch conduit open on the end penetrating the wall. These findings were confirmed by Staff MM at the time of the observations.

Based on observation and staff interview, the facility failed to ensure illumination was provided throughout the exit egress to public way. This had the potential to affect all patients, staff, and visitors to the facility. The facility census was 64.

Findings include:

1. Observation of the exit discharge from the Southwest exit access corridor completed 08/10/15 revealed approximately 50 yards of black top to public way, and no lighting was noted in the area. This was confirmed by Staff MM and Staff NN on 08/13/13 at 10:30 AM.

Based on observation and staff interview, the facility failed to ensure all areas of the facility were protected with an approved automatic sprinkler system. This had the potential to affect all patients, staff, and visitors at the facility. The facility census was 64.

Findings include:

1. Tour of the kitchen area was conducted on 08/10/15, and observation of the walk in freezer and refrigerator was completed. No sprinkler heads were noted in these areas. These findings were confirmed by Staff MM at the time of the observation.

2. Interview with Staff MM on 08/10/15 at 3:03 PM confirmed the facility already identified this issue and had ordered the proper sprinkler heads for instillation.

Based on observation and staff interview, the facility failed to ensure doors in exit egress swung in the direction of egress. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of the horizontal exit egress from the 3000 and 4000 units to the existing building completed on 08/10/15 revealed three doors opening against the path of egress from the patient care areas and nurses station to the exit access corridor. This was confirmed by Staff MM on 08/10/15.

Based on observation and staff interview, the facility failed to have documentation showing the newly introduced upholstered furniture meet the char length and heat release criteria. This had the potential to affect all patients, staff, and visitors at the facility. The facility census was 64.

Findings include:

1. Tour of the 3000 and 4000 patient care areas completed on 08/10/15 revealed 12 pieces of black furniture which included couches, love seats, and chairs.

2. Request was made for documentation on the furniture's flammability on 08/11/15 at 10:00 AM. The facility was unable to provide the documentation before the exit date of 08/13/15.

Based on observation and staff interview, the facility failed to have documentation showing the newly introduced upholstered furniture meet the char length and heat release criteria. This had the potential to affect all patients, staff, and visitors at the facility. The facility census was 64.

Findings include:

1. Tour of the entrance and 2000 patient care area completed on 08/10/15 revealed eight pieces of black furniture which included couches, love seats, and chairs.

2. Request was made for documentation on the furniture's flammability on 08/11/15 at 10:00 AM. The facility was unable to provide the documentation before the exit date of 08/13/15.

Based observation and staff interview, the facility failed to protect the linen storage area with a one hour fire rated structure. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of room 145 on 08/10/15 revealed 3 linen bag containers approximately 32 gallons each being used for soiled linen storage and a 32 gallon biohazard container. These findings were confirmed by Staff MM on 08/10/15 at approximately 2:30 PM.

2. Interview with Staff MM on 08/10/15 at 2:30 PM revealed staff are only supposed to have one linen container in room 145 and not the 3 that were present.

3. Observation above the drop ceiling completed on 08/10/15 in room 145 revealed multiple penetrations on all four walls varying in size and shape. These findings were confirmed by Staff MM on 08/10/15 at 2:35 PM.

4. Observation above the drop ceiling in the corridor outside room 145 on 08/10/15 revealed multiple penetrations varying in size and shape in the walls between room 145 and the corridor. These findings were confirmed by Staff MM on 08/10/15 at 2:36 PM.

Based on observation and staff interview, the facility failed to have a remote annunicator panel with visual and audible alarms in a location manned during all operating hours. This had the potential to affect all patients, staff, and visitors to the facility. The facility census was 64.

Findings include:

1. Observation of the generator completed on 08/11/15 revealed a generator set on the generator. A remote annunicator panel was noted in room 136 (Electrical room).

2. Interview with Staff MM and Staff NN completed on 08/13/15 at 10:45 AM revealed that the remote annunicator panel is not manned during all operating hours.

Based on review of the facility schematic, Certification of Use and Occupancy, staff interview and confirmation, the facility failed to ensure the building construction type and height met the requirements of 18.1.6.2 in regards to an unprotected wood frame. The facility capacity is 64 with a census of 64 at the time of the survey.

Findings include:

1. Review of the Certification of Use and Occupancy completed on 08/10/15 revealed a construction type of V (000). This was confirmed by Staff MM on 08/13/15 at 11:00 AM.

2. On 08/11/15 at 8:30 AM, observation of the attic space was completed and revealed unprotected wood framing and unprotected wood roofing. This was verified by Staff NN at the time of the observation.

2. Review of Building #2 drawings revealed the construction type of V (000) with no rated ceiling throughout Building #2's central space was noted on the drawings provided.

Based on observation and staff interview, the facility failed to ensure spaces open to the corridor were protected with an electronically supervised automatic smoke detection system. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of the 2000 unit lounge was noted to be open to the corridor and to not be under direct staff supervision or have an electronically supervised automatic smoke detection system.

2. Interview with Staff MM completed on 08/13/15 at 11:10 AM confirmed the lack of smoke detection in the 2000 unit lounge.

Based on Life Safety drawings, observation, and staff interview, the facility failed to ensure doors in the fire rated walls of the Southwest exit access corridor were self closing. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of the Southwest exit access corridor completed on 08/10/15 revealed the door of room 150 was noted to not have a self closing device and was open upon arrival to the area. This was confirmed by Staff MM on 08/10/15 at 1:40 PM.

Based on observation and staff interview, the facility failed to protect their hazardous areas with a one hour fire rated structure. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of room 136 (Electrical room) completed on 08/10/15 revealed multiple electrical panels and equipment producing a degree of heat. This was confirmed by Staff MM on 08/10/15 at 2:00 PM.

2. Observation above the drop ceiling of room 137 (Bathroom) completed on 08/10/15 at 2:05 PM revealed multiple penetrations in the Northeast wall and it was not sealed at the deck above. These findings were confirmed by Staff MM at the time of the observation.

3. Review of the Life Safety drawings provided by the facility revealed no one hour fire rated walls around the room 136.

Based on review of Life Safety Drawings, observation, and staff interview, the facility failed to maintain the one hour fire rated protection in the exit access corridors. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Review of the Life Safety Drawings completed on 08/10/15 revealed an exit access corridor located in the Southwest side of the building and between the new construction and the existing construction.

2. Observation of the doors in the Southwest exit access corridor completed on 08/10/15 revealed both doors and door frames from the patient care corridor to the exit access corridor were rated for 20 minutes. This was confirmed by Staff MM on 08/10/15 at 1:45 PM.

3. Observation of the doors to rooms 123, 124, 150, and 151 completed on 08/10/15 revealed 20 minute doors and door frames in the one hour wall of the Southwest exit access corridor. This was confirmed by Staff MM on 08/10/15 at 1:40 PM.

4. Observation above the drop ceiling above the exit access door in the patient care corridor outside room 125 completed on 08/10/15 revealed a 1/2 inch by 2 inch hole. This was confirmed by Staff MM on 08/10/15 at 2:40 PM.

5. Observation of the doors located in the one hour wall of the exit access corridor between the new and existing buildings completed from 08/10/15 through 08/13/15 revealed 20 minute doors and door frames, four of which had 20 minute glass panels in the doors. This was confirmed by Staff MM at the time of the observations.

6. Observation above drop ceiling above the West exit access door from the patient care area to the exit access corridor between the new building and existing building completed on 08/101/5 at 1:55 PM revealed a 6 inch water pipe with a 3/4 inch open gap and 2 half inch holes, one with 2 white and 2 gray data cables passing through. These findings were confirmed by Staff MM at the time of the observation.

7. Observation above the drop ceiling in the exit access corridor above the West exit access door from the patient care area completed on 08/10/15 at 1:57 PM revealed a 6 inch water pipe with a 3/4 inch open gap and 2 half inch holes, one with 2 white and 2 gray data cables passing through. These findings were confirmed by Staff MM at the time of the observation.

8. Observation above the drop ceiling in the exit access corridor between the new building and existing building outside room 134 completed on 08/10/15 at 2:12 PM revealed a 3/4 inch conduit penetrating the one hour wall with red data cables open on the end and a 2 inch conduit with red data cables open on the end and with open annular space. These findings were confirmed by Staff MM at the time of the observation.

9. Observation of the one hour rated wall, above the drop ceiling in room 134 completed on 08/10/15 at 2:15 PM revealed 1/2 inch hole with gray and white data cables and a 3/4 inch conduit open on the end penetrating the wall. These findings were confirmed by Staff MM at the time of the observations.

Based on observation and staff interview, the facility failed to ensure illumination was provided throughout the exit egress to public way. This had the potential to affect all patients, staff, and visitors to the facility. The facility census was 64.

Findings include:

1. Observation of the exit discharge from the Southwest exit access corridor completed 08/10/15 revealed approximately 50 yards of black top to public way, and no lighting was noted in the area. This was confirmed by Staff MM and Staff NN on 08/13/13 at 10:30 AM.

Based on observation and staff interview, the facility failed to ensure all areas of the facility were protected with an approved automatic sprinkler system. This had the potential to affect all patients, staff, and visitors at the facility. The facility census was 64.

Findings include:

1. Tour of the kitchen area was conducted on 08/10/15, and observation of the walk in freezer and refrigerator was completed. No sprinkler heads were noted in these areas. These findings were confirmed by Staff MM at the time of the observation.

2. Interview with Staff MM on 08/10/15 at 3:03 PM confirmed the facility already identified this issue and had ordered the proper sprinkler heads for instillation.

Based on observation and staff interview, the facility failed to ensure doors in exit egress swung in the direction of egress. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of the horizontal exit egress from the 3000 and 4000 units to the existing building completed on 08/10/15 revealed three doors opening against the path of egress from the patient care areas and nurses station to the exit access corridor. This was confirmed by Staff MM on 08/10/15.

Based on observation and staff interview, the facility failed to have documentation showing the newly introduced upholstered furniture meet the char length and heat release criteria. This had the potential to affect all patients, staff, and visitors at the facility. The facility census was 64.

Findings include:

1. Tour of the 3000 and 4000 patient care areas completed on 08/10/15 revealed 12 pieces of black furniture which included couches, love seats, and chairs.

2. Request was made for documentation on the furniture's flammability on 08/11/15 at 10:00 AM. The facility was unable to provide the documentation before the exit date of 08/13/15.

Based on observation and staff interview, the facility failed to have documentation showing the newly introduced upholstered furniture meet the char length and heat release criteria. This had the potential to affect all patients, staff, and visitors at the facility. The facility census was 64.

Findings include:

1. Tour of the entrance and 2000 patient care area completed on 08/10/15 revealed eight pieces of black furniture which included couches, love seats, and chairs.

2. Request was made for documentation on the furniture's flammability on 08/11/15 at 10:00 AM. The facility was unable to provide the documentation before the exit date of 08/13/15.

Based observation and staff interview, the facility failed to protect the linen storage area with a one hour fire rated structure. This had the potential to affect all patients, staff, and visitors in the facility. The facility census was 64.

Findings include:

1. Observation of room 145 on 08/10/15 revealed 3 linen bag containers approximately 32 gallons each being used for soiled linen storage and a 32 gallon biohazard container. These findings were confirmed by Staff MM on 08/10/15 at approximately 2:30 PM.

2. Interview with Staff MM on 08/10/15 at 2:30 PM revealed staff are only supposed to have one linen container in room 145 and not the 3 that were present.

3. Observation above the drop ceiling completed on 08/10/15 in room 145 revealed multiple penetrations on all four walls varying in size and shape. These findings were confirmed by Staff MM on 08/10/15 at 2:35 PM.

4. Observation above the drop ceiling in the corridor outside room 145 on 08/10/15 revealed multiple penetrations varying in size and shape in the walls between room 145 and the corridor. These findings were confirmed by Staff MM on 08/10/15 at 2:36 PM.

Based on observation and staff interview, the facility failed to have a remote annunicator panel with visual and audible alarms in a location manned during all operating hours. This had the potential to affect all patients, staff, and visitors to the facility. The facility census was 64.

Findings include:

1. Observation of the generator completed on 08/11/15 revealed a generator set on the generator. A remote annunicator panel was noted in room 136 (Electrical room).

2. Interview with Staff MM and Staff NN completed on 08/13/15 at 10:45 AM revealed that the remote annunicator panel is not manned during all operating hours.