HospitalInspections.org

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Based on observation and interview, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.1, and 7.1.10.1

This deficiency could affect 15 patients.

Findings include:

On 03/14/2018, during a tour of the facility from 7:45 am to 4:30 pm, the surveyor observed the emergency exit (as it was clearly marked) for the Dialysis Unit Suite (located on the third floor) was through an office space was blocked by a chair and a foot stool.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain the 1 hour fire resistance rating of the elevator shaft per the requirements of:

2012 NFPA 101, 19.3.1.1

Findings include:

On 03/14/2018, during a tour of the facility from 7:45 am to 4:30 pm, the elevator shaft on the 3rd Floor was observed with unsealed penetrations around the sprinkler pipe. The pipe was located at the top left hand side of shaft.

A member of the maintenance staff was present when this deficiency was identified.



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Based on observation and interview, the facility failed to provide a self-closing device for a hazardous room's door per the requirements of:

2012 NFPA 101, 19.3.2.1.3

This deficiency could affect 20 residents.

Findings include:

On 03/14/2018, during a tour of the facility from 7:45 pm to 4:30 pm, the Enviromntal storage and the Orthepedic storage Room's were observed to be over 50 sq. ft., containing combustibles materials (cardboard boxes), and the door's were observed without a self-closing device.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to ensure synchronization of visible notification devices for fire alarm per the requirements of:

2012 NFPA 101, 19.3.4.3.1, 9.6.3.5
2010 NFPA 72, 18.5.4.4.7

This deficiency could affect 2 of 10 smoke compartments.

Findings include:

On 03/14/2018, during a tour of the facility from 7:45 am to 4:30 pm, the surveyor observed 3 fire alarm strobe lights not synchronized in the field of view on the Out-Patient Hall upon activation of fire alarm system..

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 7.2.1.2, and 7.3.1.1.1

Findings include:

On 03/14/2018, during a tour of the facility from 7:45 am to 4:30 pm, the surveyor observed a fire extinguisher in the Cath. Lab's Storage Room (located on the third floor) with the following:
1. Last annually inspection was 01/2017
2. Last monthly inspection was 06/14/2017

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain a corridor door per the requirements of:

2012 NFPA 101, 19.3.6.3.2 (2)

Findings include:

On 03/14/2018, during a tour of the facility from 7:45 am to 4:30 pm, the surveyor observed a transfer grill in the Med. Gas Storage Room's corridor door, located on the third floor next to the elevator.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3 and 8.5.1

Findings include:

On 03/13/2018, during a tour of the facility from 7:45 am to 4:30 pm, the surveyor observed the Smoke Wall on left hand side of the Boiler room near the rear of the room to have four 2" copper pipes that were not sealed around and did not create the resistance rating for the Smoke Wall.



A member of the maintenance staff was present when the deficiency was identified.

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Based on review of documentation and interview, the facility failed to provide a fire safety plan containing all nine items per the requirements of:

2012 NFPA 101, 19.7.2.2 (3)

Findings include:

On 03/14/2018, during a tour of the facility from 7:45 am to 4:30 pm, the facility provided a fire safety plan, that did not contain item #3 "emergency phone call to the fire department".

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to conduct fire drills per the requirements of:

2012 NFPA 101, 19.7.1.6

This deficiency could affect All residents.

Findings include:

On 03/14/2018, during a review of documentation from 7:45 pm to 4:30 pm, the surveyor observed that the fire drills for the first, second, and third shifts had only 10 to 15 signatures on each shift, Full participation is required for each drill.

A member of the maintenance staff and administrator was present, when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain a mobile soiled linen barrel per the requirements of:

2012 NFPA 101, 19.7.5.7.1 (3)

Findings include:

On 03/14/2018, during a tour of the facility from 7:45 am to 4:30 pm, the surveyor observed an approximately 96 gallon mobile soiled linen barrel unattended in the corridor by the Blood Gas Lab located on the third floor.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

Findings include:

On 03/14/2018, during a tour of the facility from 7:45 am to 4:30 pm, the surveyor observed a portable space heating device that was on and up aganist the wood desk at Nurses' Station 4 Central. This was located in a patient sleeping smoke compartment and the facility was unable to provide documentation on the heating element not exceeding 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.

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