HospitalInspections.org

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2012 Life Safety Code (LSC). The building was not equipped with a complete automatic fire sprinkler system. Findings include:

1. Observation at 9:00 a.m. on 6/18/19 revealed the building was a two story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Record review of the previous survey conducted on 3/27/18 confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column (X5).

Based on observation and record review, the provider failed to install a paved path of exit discharge to the public way at one exit (south exit stair enclosure) of the building. Findings include:

1. Observation at 10:30 a.m. on 6/18/19 revealed the exit from the south exit stair enclosure had a landing that ended approximately 210 feet from the nearest street. Review of the previous survey conducted on 3/27/18 confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column (X5).

Based on observation and interview, the provider failed to ensure adequate illumination of means of egress was provided at five of five exit discharge locations. Findings include:

1. Observation at 8:45 a.m. on 6/18/19 revealed the main entrance was equipped with a multiple diode LED exit discharge light. Interview with the administrator at the time of the observation revealed the light was on the emergency power circuit from the generator. Testing of the fixture revealed the light would not turn on and illuminate. The administrator stated all the exit discharge lights were on a timer that effectively shut them off prior to the scheduled time to be turned on. He was not aware that exit discharge lighting was not in compliance with the requirements.

This deficiency had the ability to affect 100% of the building exits in an emergency.

Based on observation and interview, the provider failed to maintain fire separation for one randomly observed hazardous area (record keeping on second floor) as required. Findings include:

1. Observation at 10:30 a.m. on 6/18/19 revealed the record keeping room was an office combined with paper file storage. The room was over 100 square feet in area and had large amounts of combustible storage. The corridor door was not equipped with a closer. The second floor also had the QA office, the CPA office, and the pharmacy in addition to the record keeping room.

Interview with the administrator at the time of the observations confirmed those findings.

The deficiency affected one of numerous requirements for hazardous storage rooms.