HospitalInspections.org

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 100% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on August 21, 2013 at 10:30 a.m., the maintanance supervisor and the surveyor observed the smoke barrier walls had the following small data cable size unsealed penetrations:

1. East Wing smoke barrier wall had small unsealed penetrations between Rooms 208 and 210.
2. Smoke barrier wall in Room 211 had unsealed penetrations around data cable.
3. Smoke barrier wall located between the emergency room and surgery area had small data cable unsealed penatrations.

This deficient practice has the potential of affecting 4 of 4 smoke compartments.

The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

While inspecting hazardous areas on August 21, 2013 at 11:00 a.m., the maintenance person and the surveyor found the following hazardous areas not to have self closing devices on rated doors:

1. Biohazard room near nursing station on the West Wing

2. Dirty linen room near nursing station on the West Wing

3. Storage closet near nursing station on the West Wing

This deficient practice has the potential of affecting one (1) of four (4) smoke compartments.

The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on record review, the facility failed to properly insure the operability of the sprinkler system as required by NFPA 13 5-5.5.1 This condition affected 25 of the 49 residents in the facility on the day of survey.

Findings Include;

On August 22, 2013 at 12:15 pm, the maintenance office, central supply closet in the Emergency Room and the Sterilize Supply Room are obstructed by drop down ceiling tile. The maintenance person and surveyor also found the sprinkler head in surgical suite to be obstructed by ceiling.

5-5.5.1* Performance Objective.
Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A-5-5.5.1.)

5-5.5.2* Obstructions to Sprinkler Discharge Pattern Development.

5-5.5.2.1* Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.

5-5.5.2.2* Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.

5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard.
Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect about 100% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on August 21, 2013 at 10:30 a.m., the maintanance supervisor and the surveyor observed the smoke barrier walls had the following small data cable size unsealed penetrations:

1. East Wing smoke barrier wall had small unsealed penetrations between Rooms 208 and 210.
2. Smoke barrier wall in Room 211 had unsealed penetrations around data cable.
3. Smoke barrier wall located between the emergency room and surgery area had small data cable unsealed penatrations.

This deficient practice has the potential of affecting 4 of 4 smoke compartments.

The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

While inspecting hazardous areas on August 21, 2013 at 11:00 a.m., the maintenance person and the surveyor found the following hazardous areas not to have self closing devices on rated doors:

1. Biohazard room near nursing station on the West Wing

2. Dirty linen room near nursing station on the West Wing

3. Storage closet near nursing station on the West Wing

This deficient practice has the potential of affecting one (1) of four (4) smoke compartments.

The Administrator and Maintenance Director were notified during the survey and in the exit conference.

Based on record review, the facility failed to properly insure the operability of the sprinkler system as required by NFPA 13 5-5.5.1 This condition affected 25 of the 49 residents in the facility on the day of survey.

Findings Include;

On August 22, 2013 at 12:15 pm, the maintenance office, central supply closet in the Emergency Room and the Sterilize Supply Room are obstructed by drop down ceiling tile. The maintenance person and surveyor also found the sprinkler head in surgical suite to be obstructed by ceiling.

5-5.5.1* Performance Objective.
Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A-5-5.5.1.)

5-5.5.2* Obstructions to Sprinkler Discharge Pattern Development.

5-5.5.2.1* Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.

5-5.5.2.2* Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.

5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard.
Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.