HospitalInspections.org

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Based on observation and interview, the facility failed to maintain two 1.5 hour fire rated doors in the two hour fire rated barrier separating the three story construction type II (222) from the one story construction type II (000) (not allowed in a three story building) per the requirements of:

2012 NFPA 101, 19.1.1.4.1.1, and 8.3.3.1
2010 NFPA 80, 5.2.4

On 05/22/2019, during a tour of the facility from 8:15 am to 2:30 pm, the surveyor observed two 1.5 hour fire rated doors in the two hour fire rated barrier separating the kitchen from the Dining Room failed to fully close and latch. It appeared to this surveyor that the door casings of both doors were impeding these doors from closing and latching. The surveyor also observed gaps on both doors allowing the surveyor to see visible light pass through the opening created by these door casings.

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 hazardous rooms per the requirements of:

2012 NFPA 101, 19.3.2.1.2, and 19.3.2.1.3

This deficiency could affect 35 occupants.

Findings include:

On 05/22/2019, during a tour of the facility from 8:15 am to 2:30 pm, the surveyor observed room 222 was over 50 sq. ft. and was being used to store supplies, cardboard boxes and various cloth material. The door was without a self-closing device.

A member of maintenance staff was present when the facility was identified.
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Based on review of documentation, observation and interview, the facility failed to maintain the kitchen hood per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 11.2.1, 11.4, Table 11.4, and 11.6

This deficiency could affect 1 smoke compartment.

Findings include:

On 05/22/2019, during a tour of the facility from 8:15 am to 2:30 pm, the facility failed to provide documentation of a kitchen hood cleaning being conducted within the past 6 months. The facility failed to provide documentation of the last kitchen hood cleaning.

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 portable fire extinguishers per the requirements of:

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

This deficiency could affect 1 out of 7 smoke compartments.

Findings include:

On 05/22/2019, during a tour of the facility from 8:15 am to 2:30 pm, the surveyor observed the last annual inspection of the Admission Office's fire extinguisher was February 2018 by Covington Fire Protection.

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

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

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

This deficiency could affect 20 occupants.

Findings include:

On 05/22/2019, during a tour of the facility from 8:15 am to 2:30 pm, the surveyor observed the following:
1. Orange non-fire rated foam sealant used to seal penetrations in the 2nd floor smoke barrier above the ceiling at the elevators.

2. Three 1/2" unsealed holes in the 3rd floor smoke barrier at the dumbwaiter.

A member of the maintenance staff was present when this deficiency was identified.
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Based on the review of documentation and interview, the facility failed to maintain the required fire doors in the two hour fire rated barrier separating the three story construction type II (222) from the one story construction type II (000) (not allowed in a three story building) per the requirements of:

2012 NFPA 101, 19.7.6, and 8.3.3.1
2010 NFPA 80, 5.2, and 5.2.3

This deficiency could affect 35 occupants.

Findings include:

On 05/22/2019, during a tour of the facility from 8:15 am to 2:30 pm, the facility failed to provide documentation of its annual fire door inspection and testing within the past 12 months for the kitchen roll down fire assembly doors located in the two hour fire rated barrier separating the kitchen from the Dining Room at the following locations:

1. At the dish collection window
2. In front of the Victory Warmer equipment

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Based on review of documentation and interview, the facility failed to maintain the Level 1 EPSS diesel generator per the requirements of:

2012 NFPA 99, 6.4.4.1.1.3, and 6.4.4.2
2010 NFPA 110, 1.3, 8.4.9

Findings include:

On 05/22/2019, during a tour of the facility from 8:15 am to 2:30 pm, based on review of documentation and interview the facility failed to provide documentation of the Level 1 EPSS test conducted within the past 36 months.

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 maintain the Level 1 EPSS diesel generator per the requirements of:

2012 NFPA 99, 6.4.4.1.1.3, and 6.4.4.2
2010 NFPA 110, 1.3, 8.4.9

Findings include:

On 05/22/2019, during a tour of the facility from 8:15 am to 2:30 pm, based on review of documentation and interview the facility failed to provide documentation of the Level 1 EPSS test conducted within the past 36 months.

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 oxygen cylinders per the requirements of:

2012 NFPA 99, 11.3.2.3

This deficiency could affect 2 occupants.

Findings include:

On 05/22/2019, during a tour of the facility from 8:15 am to 2:30 pm, the surveyor observed the oxygen cylinders being stored within 5 feet of combustible material (cardboard boxes) in the unsprinklered room next to the Nuclear Medicine Room.

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